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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/bilharziosisOOmadd 


Fig  1.— The  bilharzia  worm  (Schistosomum  haematobium).  To  the  right 
is  a  coupled  pair  of  worms,  the  female  lodged  in  the  gynecophoric 
canal  of  the  male.  To  the  left  is  seen  a  cross-section  of  a  pair, 
to  show  the  mode  of  formation  of  the  gynecophoric  canal,  in  which 
a  single  cross-section  of  the  female  worm  is  visible.  Both  figures 
semi-diagrammatic. 

(Photograph  of  a  drawing  by  Professor  Looss,  figured  in  Mense's  "Handbttch 
der  Tropen-UranlJiciten"  Vol.  1.) 


BILHARZIOSIS 


BY 


FRANK   COLE   MADDEN 


M.D.Melb.,    F.R.C.S.Eng. 

professor  of  surgery  egyptian  government  school   of  medicine,  senior 
surgeon  kasr-el-ainy  hospital,  cairo 


ILLUSTRATED 


NEW    YORK 
WILLIAM    WOOD    AND    COMPANY 

MDCCCCVII 


PATHOL  rnpvl 


RC 
'Si 

Ml3 
Won 


PREFACE. 

In  this  monograph  I  have  endeavoured  to  give  a 
resume  of  the  present  state  of  our  knowledge  of 
Bilharziosis ;  and,  in  doing  so,  have  naturally  had 
to  draw  largely  upon  the  work  and  experience  of 
others  in  the  same  field.  To  these  observers  I 
wish  here,  at  the  outset,  freely  and  frankly  to 
acknowledge  my  great  indebtedness. 

I  am  especially  beholden  to  my  friend  and  col- 
league, Professor  Looss,  who  has  taken  infinite  pains 
in  providing  me  with  an  abstract  of  that  portion  of 
his  article  in  Mense's  "  Handbuch  der  Tropen- 
krankheiten"  which  deals  with  the  life-history  and 
mode  of  infection  of  the  Bilharzia  worm. 

Again,  much  of  the  pathological  description  of 
the  disease  is  the  result  of  a  study  of  specimens 
in  the  Pathological  Museum  of  the  School  of  Medi- 
cine in  Cairo,  prepared  by  Professor  W.  St.  Clair 
Symmers,  formerly  Professor  of  Pathology  in  this 
School,  now  Musgrave  Professor  of  Pathology  in 
Queen's  College,  Belfast.  For  his  kindness  in  re- 
el vising  an  earlier  manuscript  of  mine  on  the  subject 
.    and   allowing   me  to    avail  myself    so  fully   of  the 


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vi  PREFACE. 

material  at  his  disposal,  I  am  deeply  grateful;  but 
I  must  accept  all  responsibility  for  any  inaccuracies 
that  may  appear  in  the  text. 

In  the  clinical  paragraphs  I  have  included  much 
of  the  work  published  by  my  former  colleague,  Mr. 
Frank  Milton,  in  various  papers,  in  my  endeavour 
to  make  this  side  of  the  picture  as  complete  as 
possible ;  and,  throughout  the  whole  monograph, 
I  have  avoided  the  discussion  of  controversial  points, 
upon  which  much  work  is  still  to  be  done,  and  have 
tried  to  approach  the  subject  from  the  standpoint 
of  a  practical  surgeon. 

I  am  also  indebted  to  Dr.  H.  P.  Keatinge,  the 
Director  of  the  School,  for  his  ready  assent  to  the 
publication  of  photographs  of  specimens  and  cases 
from  the  School  collections ;  and,  finally,  to  my 
friend  and  colleague,  Professor  A.  R.  Ferguson, 
the  present  Professor  of  Pathology  in  the  School 
of  Medicine,  for  so  carefully  revising  with  me  the 
whole  manuscript,  I  take  this  opportunity  of  ex- 
pressing my  sincerest  thanks. 

Cairo,  1907. 


CONTENTS. 


The  Parasite 


PAGE 

9 


II. 

The  Pathological  Changes   produced   by  Bilharzia         .     18 


III. 


Bilharziosis   op  the  Urinary   System 


30 


IV. 


Bilharziosis   op   the   Intestinal   Tract 


64 


V. 


Bilharziosis   of  the  Female   Generative   Organs 


73 


VI. 


Bilharziosis  of  the  Skin  and  Subcutaneous  Tissues 


7o 


LIST   OF   ILLUSTRATIONS. 

Fig.   1. — The  bilharzia  worm         ....         Frontispiece 

„      2. — Section  of  bilharzial  tissue  in  the  meso- 

recturu         ......   To  face  page  10 

,,      3. — A  bilharzia  ovum  in  the  urine  .  .  ,,         ,,10 

,,      4. — Section  of  bilharzial  cirrhosis  of  the  liver         ,,  ,,      12 

„      5. — Free-swimming  bilharzial  miracidium        .  ,,  ,,12 

,,      6. — Section      of     portion     of     a     bilharzial 

papilloma     .  .  .  .  .  .  ,,  ,,18 

,,      7. — The  mucus  membrane  in  early  bilharziosis 

of  the  bladder       .....,,,,      18 

„      8. — More  advanced  bilharziosis  of  the  bladder         ,,  ,,     22 

,,      9. — Bilharzial  papillomata  in  the  large  intestine         ,,  ,,     22 

,,  10. — Ulceration  of  the  large  intestine  ("  bilhar- 
zial dysentery ")   .  .  .  .  .  ,,         ,,     27 

,,    11. — Extreme  case  of  bilharziosis  of  the  bladder         ,,  ,,      27 

„    12. — Section  of    "bilharzial    scirrhus  "  of  the 

bladder „     29 

„    13. — Advanced  bilharziosis  of  the  bladder         .  ,,  ,,36 

,,    14. — Bilharziosis  of  the  penis  and  scrotum  in 

a  young  boy „         „     57 

„    15. — Bilharziosis  of  the  penis  in  a  boy  of  nine .  .,  ,,     59 

,,    16. — Bilharziosis   of   the   sigmoid  flexure  and 

meso-sigmoid        .  .  .  .  .  ,,         ,,68 

„    17. — Bilharzial    papillomata    protruded    from 

the  anus       ......         n         „     68 

,,  18. — Bilharzial  papillomata  of  the  vulva  grow- 
ing from  the  left  labium  majus  „  ,,      73 

,,    19 — Smaller  papillomatous  mass  growing  from 

right  labium  majus  in  same  case  .  ,,         ,,     74 

,,    20. — Bilharziosis    of    the    vulva    and    vaginal 

orifice.         .....         To  follov)  Fig.  19 

,,  21. — Bilharzial  papilloma  growing  from  pos- 
terior lip  of  cervix  uteri         .  .  .    To  face  page  76 

,,    22. — Scarring  left  after  operations  on  bilharzial 

sinuses         ......„„     76 

,,   23. — Epithelioma  around   anus  originating    on 

site  of  old  bilharzial  disease  ..,,,,     76 

,.  24. — Epithelioma  of  the  penis,  scrotum,  and 
inguinal  glands  secondary  to  old 
bilharziosis.  ....  To  follov)  Fig.  23 


BILHARZIOSIS. 
I. 

THE  PARASITE, 

The  pathological  conditions  included  in  the  term  bil- 
harziosis  are  produced  by  the  presence  of  the  bilharzia 
worm,  Schistosomum  hcematobium,  in  the  human  body. 

Geographical  distribution. — The  bilharzia  worm 
is  endemic  in  Egypt,  and  also,  to  a  more  limited  extent, 
in  South  Africa.  Endemic  centres  appear  to  exist  in 
Syria,  the  Soudan  and  Uganda,  Madagascar,  Mau- 
ritius, Reunion,  China,  Cyprus,  and  the  West  Indies ; 
and  sporadic  cases  of  bilharziosis,  probably  contracted 
in  one  or  other  of  these  centres,  have  been  reported 
in  many  other  countries,  for  instance,  in  England  and 
Australia,  among  the  troops  who  have  recently  returned 
from  South  Africa. 

Description  and  life-history. — The  worm  be- 
longs to  the  group  of  the  Trematodes,  but  is  dis- 
tinguished from  the  majority  of  this  group  by  having 
male  and  female  separate  individuals. 

The  male  worm,  to  the  naked  eye,  is  about  1  cm. 
long,  milky-white  in  colour,  cylindrical  in  shape  with 
tapering  extremities.  Microscopically,  its  body  is  seen 
to  be  thickly  studded  with  minute  warty  projections, 
each  tipped  with  short  stout  bristles.     Two  suckers, 


10  BILEABZIOSIS. 

one  behind  the  other,  are  seen  on  the  under  surface 
of  the  body,  near  the  anterior  extremity.  Under  the 
microscope  it  will  also  be  seen  that  the  body  of  the 
worm  is  not  cylindrical,  but  thin  and  flattened,  and 
that  the  lateral  margins  of  the  body  are  folded  towards 
the  ventral  surface  to  form  a  long  open  canal — the 
gynecophoric  canal — in  which  the  female  lies  during 
the  period  of  sexual  activity. 

The  female  worm  is  much  longer  and  thinner  than 
the  male  and  is  often  found  lying  within  the  gyneco- 
phoric canal,  generally  with  part  of  the  anterior  and 
posterior  extremities  protruding.  She  can,  however, 
completely  withdraw  herself  into  the  canal.  (Figs.  1 
and  2.) 

The  most  common  habitat  of  the  worm  is  the 
portal  vein  and  its  tributaries  within  the  liver. 

Here  the  worms  are  small,  often  very  small,  are 
not  yet  sexually  active,  and  the  male  and  female 
occur  separately,  not  coupled.  Exceptionally,  how- 
ever, coupled  pairs  of  worms  may  be  met  with  in 
this  situation. 

The  worms  are  also  found  in  the  mesenteric  veins 
and  their  larger  tributaries.  Here  they  are  larger 
than  those  found  in  the  portal  vein  and  mostly  occur 
as  coupled  pairs.  They  are  sexually  mature,  but  the 
female  does  not  contain  many  ova. 

The  other  common  habitat  of  the  worm  is  the 
vessels  of  the  submucous  tissue  of  the  bladder  and 
rectum  and,  to  some  extent,  also,  of  other  parts  of 
the  intestinal  tract. 


Fig.  2. — Photo-micrograph  of  section  of  bilharzial  tissue  in  the  meso-rectum 
(see  Fig.  16),  showing  several  coupled  pairs  of  worms  in  situ.  To 
the  left  and  above,  the  female  has  been  so  much  coiled  up  that 
three  cross-sections  of  it  have  been  made.  Below  and  to  the  right 
no^female  is  present. 

(From  a  preparation   b%i  Professor  Looss,  figured  in  Mcnse's  "  Handbueh 
dcr  Tropen-l;rcm~kheiten,"  Vol.  1.) 


Fig.  3.— A  bilharzia  ovum,   with  calcified  contents,   in  the  urine.     The 
shell  and  its  end  spine  are  particularly  well  seen. 

(From   a  photo-micrograph  in  the  Photographic  Album   of  the  School  of 
Medicine,  Cairo.) 


THE  PARASITE.  11 

Worms  found  in  these  situations  are  fully  de- 
veloped, physically  and  sexually,  they  nearly  always 
occur  in  coupled  pairs,  and  the  uterus  of  the  female  is 
distended  with  ova. 

Exceptionally,  worms  may  be  found  in  the  vessels 
of  other  organs  of  the  body,  notably  the  lungs 
(Symmers). 

From  these  observations  it  would  appear  that  the 
worms  travel  from  the  liver  in  the  veins  of  the  portal 
system  generally,  to  the  vessels  in  the  submucous 
tissue  of  the  bladder  and  rectum  and  other  parts  of 
the  intestine.  Some  even  escape  into  systemic 
veins,  by  way  of  their  communications  with  the 
portal  system,  and  may  thus  reach  the  lungs  or 
other  organs  even  more  distant. 

It  will  be  noted  that  the  course  of  the  worms  is 
against  the  blood  stream.  This  mode  of  progression 
is  probably  effected  by  strong  muscular  movements  on 
the  part  of  the  male  worm,  which  carries  the  female, 
lodged  in  its  gynecophoric  canal,  with  it. 

The  ova  are  of  a  blunt  spindle  shape,  about  0*16 
mm.  long  on  an  average.  They  are  encased  in  a  thin 
yellowish  shell.  Two  forms  of  ova  are  to  be  distin- 
guished. The  most  common  (normal)  ovum  has  a 
terminal  spine,  which  may  vary  in  size  within  narrow 
limits  in  different  ova,  or  even  be  entirely  absent. 
The  second  (abnormal)  ovum  presents  a  large  lateral 
spine,  which  varies  considerably  in  size  and  position. 
These  lateral-spined  ova  are  usually  seen  in  small 
numbers   in   the   uterus   of   young   females   and  are 


12  BILHARZIOSIS. 

commonly  found  in  the  liver,  and,  more  rarely,  in  the 
lungs.     (Figs.  3  and  4.) 

The  ova  are  laid  into  the  blood  and  the  laying 
begins  when  the  female  is  still  in  the  liver.  The  ova, 
being  thus  free  in  the  blood-stream,  are  washed  away 
through  the  larger  vessels  until  they  reach  a  smaller 
capillary  than  they  can  traverse,  and  here  they  become 
impacted.  Thus,  the  ova  that  are  laid  when  the 
worms  are  still  in  the  portal  vein,  or  in  the  larger 
veins  of  the  portal  system,  may  be  washed  back  into 
the  liver  and  become  fixed  there ;  or  may  even  pass 
through  this  organ  and  reach  the  pulmonary  or  the 
systemic  circulation.  In  the  latter  case  they  are 
ultimately  infarcted  in  the  smaller  capillaries  of 
distant  tissues  or  viscera. 

When  the  ova  are  laid  in  the  smaller  vessels,  as, 
for  instance,  in  those  of  the  submucous  tissue  of  the 
bladder  or  rectum,  the  capillaries  may  become  com- 
pletely packed  with  ova,  to  such  an  extent  that  the 
walls  of  the  vessels  burst  and  the  ova  pass  into  the 
substance  of  the  organ  and  become  fixed  there.  By 
the  muscular  movements  of  the  viscus,  aided  also  by 
their  peculiarly  penetrating  shape,  the  ova  slowly 
travel  in  the  organ  ;  and  some  approach  the  surface  of 
the  mucous  membrane  and  are  eventually  extruded  and 
passed  with  the  urine  or  faeces.  This  movement  of 
the  ova  in  the  tissues  is  comparable  with  the  wander- 
ing of  a  needle,  which  has  penetrated  the  skin  and  lies 
loose  in  the  subcutaneous  tissues. 

In  the  exceptional  cases  in  which  worms  are  found 


Fig.  4. — Section  of  bilharzial  cirrhosis  of  the  liver,  showing  many  lateral- 
spined  ova. 

(From  a  specimen,  prepared  by  Professor  Symmers,  in  the  Pathological  Museum 
of  the  School  of  Medicine,  Cairo.    Photo-micrograph  by  Mr.  F.  S.  Willmore.) 


r 


Fig.  5. — The  free-swimming  bilharzial  miracidium.     Semi-diagrammatic. 
(From  a  wall-diagram  drawn  by  Professor  Looss,  and  figured  in  Mense's 
"  Handbuch  der  Tropen-lerankheiten,"  Vol.  1.) 


THE  PARASITE.  13 

in  the  systemic  circulation,  the  ova  are  passed  directly 
into  the  circulating  blood  and  are  thus  directly  carried 
to  unusual  seats. 

At  the  time  of  its  formation  in  the  female  the 
impregnated  ovum  contains  an  unsegmented  egg-cell 
and  a  number  of  yolk-cells.  It  is  then  much  smaller 
than  the  ova  found  in  the  tissues,  increasing  in  size  as 
the  process  of  development  goes  on  within  it.  By  the 
time  the  ovum  is  passed  in  the  urine  or  faeces  it  con- 
tains a  fully  developed  embryo  or  miracidium.  If  such 
ova  get  into  water,  or  if  water  be  added  to  the  urine 
or  faeces,  the  miracidium  hatches  out  in  a  few  minutes 
and  swims  actively  about  by  means  of  its  cilia.  In 
urine  and  in  almost  any  other  fluid,  except  water, 
the  miracidium  dies  in  about  24  hours  without  hatch- 
ing out ;  and  even  in  water,  once  it  has  hatched  out,  it 
cannot  be  kept  alive  for  longer  than  24  to  48  hours. 
(Fig.  5.) 

Many  ova  die  during  development,  and  their  con- 
tents become  granular  and  finally  calcified.  Micro- 
scopically, such  ova  present  a  blackened  opaque  ap- 
pearance. (See  Figs.  3  and  4.)  These  calcified  ova, 
indeed  all  ova,  will  vary  in  size  according  to  their 
stage  of  development. 

Further  Development.  — The  complete  cycle 
of  development  of  the  bilharzia  worm  is  still  un- 
known. From  analogy  with  other  Trematodes  it 
seemed  reasonable  to  infer  that,  in  order  to  become 
a  young  worm,  the  miracidium  must  pass  through  a 
further  stage  of  development  in  some  intermediary 


14  BILHARZIOSIS. 

host.  No  intermediary  host  has  ever  yet  been  dis- 
covered. Looss,  working  under  the  most  favourable 
conditions,  in  the  very  midst  of  bilharziosis  in 
Egypt,  has  utterly  failed  to  find  any  intermediary 
host,  or  to  induce  any  species  of  animal  or  plant 
life  to  harbour  the  miracidium.  He  is,  therefore,  of 
opinion  that  man  himself  acts  as  the  intermediary  host. 
Two  modes  of  infection  are  possible  on  this 
hypothesis. 

1.  By  the  mouth,  being  introduced  through  the 
medium  of  the  drinking  water. 

In  this  connection,  Looss  has  shown  that  free- 
swimming  bilharzia  miracidia  are  killed  in  a  1  in 
1000  watery  solution  of  hydrochloric  acid,  almost 
instantaneously,  and  in  less  than  three  minutes  in  a  1 
in  2000  solution.  For  this  reason,  infection  through 
the  stomach,  the  secretion  of  which  contains  a  stronger 
solution  of  hydrochloric  acid,  is  practically  impossible. 

2.  By  the  skin,  by  penetration.  Looss  holds  the 
view  that  the  miracidia  probably  penetrate  the  skin, 
find  their  way  to  some  resting  place,  probably  the 
liver,  and  there  pass  through  a  sporocystic  stage ;  the 
final  outcome  of  which  is  young  worms  of  both  sexes, 
similar  in  appearance  to  those  found  in  the  veins  of 
the  liver.  The  presence  of  certain  so-called  germinal 
cells  in  the  body  of  the  miracidium  indicate  con- 
clusively that  there  must  be  a  sporocystic  stage  in 
the  cycle  of  development. 

In  support  of  this  infection-by-skin  theory,  it  has 
been  noted  that,  in  the  country  districts  of  Egypt,  it 


THE  PARASITE.  15 

is  the  agricultural  labourer,  or  fellah,  who  works  all 
day  in  the  wet  irrigated  fields,  who  is  most  commonly 
affected:  and  that  it  is  the  scavengers,  street  sweep- 
ers, gardeners,  and  small  children  (who  love  to  go 
about  bare-footed  in  the  puddles  and  wet),  who  are 
especially  subject  to  bilbarziosis,  among  the  town 
dwellers.  In  the  country,  the  whole  agricultural 
population  drink  plain  unfiltered  Nile  water ;  but  in 
the  towns  the  water  is  treated  by  nitration  and  sup- 
plied by  Water  Companies.  In  spite  of  the  supposed 
protection  against  infection  thus  afforded,  certain 
classes  of  the  town-dwellers  do  become  subject  to  bil- 
harziosis;  and,  as  has  just  been  pointed  out,  the 
classes  most  affected  are  made  up  of  individuals 
whose  habits,  in  other  respects,  are  similar  to  those 
of  the  agricultural  labourer. 

Any  small  puddle  may  become  denied  with  the 
urine  or  faeces  of  a  patient  suffering  from  bilharziosis ; 
and,  in  a  very  short  time,  the  water  or  mud  is  alive 
with  miracidia,  which  may  become  applied  to  the 
bare  feet,  legs,  or  hands,  penetrate  the  skin  and 
so  lead  to  infection.  In  this  way,  too,  constant 
re-infections  may  occur  and  a  cure  is  almost  im- 
possible. 

Children  who  contract  bilharziosis  during  the  bare- 
feet  period  of  their  existence  may  grow  out  of  their 
disease  in  a  few  years'  time ;  for  re-infection  does  not 
occur,  owing  to  their  altered  habits  and  indoor  oc- 
cupations. It  has  frequently  been  noted,  also,  that 
when  a  patient  suffering  from  bilharziosis  leaves  the 


16  BILHARZIOSIS. 

country  in  which  he  contracted  it  he  may  eventually 
be  completely  cured. 

It  is  a  remarkable  fact  that,  of  the  cases  of 
bilharziosis  treated  at  Kasr-el-Ainy  Hospital,  Cairo, 
which  drains  all  parts  of  Egypt,  except  Alexandria, 
nearly  90  per  cent,  come  from  Cairo  and  the  country  to 
the  north  of  Cairo.  This  is  the  only  part  of  Egypt 
now  perennially  irrigated,  and  comprises  the  rich  agri- 
cultural lands  of  the  Delta  ;  whereas  the  country  to  the 
south  is  entirely  inundated  during  the  rise  of  the  Nile 
and,  after  its  subsidence,  receives  only  just  sufficient 
water  for  the  purposes  of  cultivation.  Thus  in  the 
north  the  fields  are  practically  always  under  water; 
while  in  the  south  the  supply  is  strictly  limited  and 
the  northern  wet  sodden  condition  of  the  ground  does 
not  prevail  (Milton). 

Of  a  total  of  1,346  cases  of  bilharziosis  admitted 
for  treatment  in  the  hospital,  during  a  certain  term  of 
years,  about  94  per  cent,  were  males ;  and  the  greater 
number  of  cases  occurred  between  the  ages  of  15  and 
45.  It  was  remarkable  that  the  proportion  of  female 
cases  to  male  was  as  1  to  9,  under  the  age  of  15  years  ; 
but  above  that  age,  when  the  girls  marry  and  begin 
to  lead  more  of  an  indoor  life,  it  was  as  1  to  20,  a  very 
significant  fact  in  view  of  what  has  already  been 
stated  regarding  the  mode  of  probable  infection 
(Milton). 

Further,  Talaat  has  shown  that  bilharziosis  in 
women  is  common  among  the  poorer  agricultural  popu- 
lation, all  of  whom  work  in  the  fields  with  the  men. 


THE  PARASITE.  17 

It  is  much  less  frequent  in  the  better  classes  and  in 
those  who  are  mainly  occupied  with  domestic  duties. 
In  the  towns,  the  disease  is  altogether  less  common 
than  in  the  country  and  is  only  met  with  in  women 
whose  work  brings  them  in  contact  with  wet  soil  or 
mud,  and  in  children,  and  it  is  quite  unknown  among 
the  better  classes. 

It  is  well  recognised  that  almost  every  Egyptian 
of  the  agricultural  class,  in  Lower  Egypt  at  all  events, 
has  had  bilharzial  hematuria  at  one  time  or  another. 
A  careful  investigation  of  a  series  of  100  consecutive 
admissions  to  the  hospital,  irrespective  of  their  disease, 
showed  that  35  of  them  had  bilharzia  ova  in  the  urine ; 
but  only  2  of  this  number  complained  of  symptoms  of 
bilharziosis  (Milton). 

A  great  many  cases  must  eventually  recover  with- 
out symptoms  at  any  time  sufficiently  serious  to  call 
for  medical  treatment ;  the  severe  cases  being  found 
among  those  whose  occupation  renders  them  particu- 
larly liable  to  repeated  re-infections  and  in  whom,, 
sooner  or  later,  septic  infection  supervenes. 


II. 

THE   PATHOLOGICAL   CHANGES   PRODUCED 
BY   BILHARZIA. 

The  pathological  effects  of  Bilharzia  are  due, 
primarily,  to  the  deposit  of  the  ova  in  the  tissues. 
These  ova  soon  excite  a  small-celled  infiltration  around 
them,  as  is  the  case  with  any  foreign  body,  and  to 
such  an  extent  may  this  infiltration  proceed  that,  at 
times,  the  true  structure  of  the  affected  parts  is  almost 
completely  replaced  by  ova,  leucocytes  and  young 
connective  tissue  cells.     (Fig.  6.) 

The  pathological  manifestations  may  be  divided 
somewhat  arbitrarily  into  two  classes  of  lesions,  the 
hypertrophic  and  the  atrophic.     In  the  former  occurs 
a  marked  proliferation  of  cells,  especially  epithelial 
cells,  leading,  particularly,  to  the  formation  of  papil- 
lomatous growths :  whereas,  in  the  atrophic  form,  the 
principal  change  is  due  to  the  presence  of  what  may 
be  called  bilharzial  granulation  tissue.     This  becomes 
fibrillar,   and,  in  fact,  goes  through  all  the  various 
changes  of  inflammatory  granulation  tissue  of  more 
acute  origin ;  the  final  result  being  a  peculiar  white 
dense  contracting  fibrous  tissue,   a  true  scar  tissue, 
which  may  contain  very  few  ova  in  its  substance. 

The  hypertrophic  form  is  especially  found  in  connec- 
ts 


Fig.  6.— Section  of  portion  of  a  bilharzial  papilloma,  showing  the  enormous 
crowding  of  the  tissues  with  ova. 

(From  a  specimen,  prepared  by  Professor  Symmers,in  the  Pathological  Museum 
of  the  School  of  Medicine,  Cairo.    Photo-micrograph  by  Mr.  F.  S.  Willmore.) 


Fig.   7.— General  swelling  and   infiltration  of  the   mucous  membrane  in 
early  bilharziosis  of  the  bladder. 

(From    a    specimen,  prepared    by    Professor   Symmers,    hi    the    Pathological 
Museum  of  the  School  of  Medicine,  Cairo.) 


PATHOLOGICAL   CHANGES.  19 

tion  with  bilharziosis  of  viscera  lined  by  mucous 
membrane ;  the  atrophic  being  more  usual  in  the 
disease  as  it  affects  the  connective  tissues,  either  of 
the  subcutaneous  area  or  of  the  viscera.  In  certain 
cases  the  two  forms  may  be  seen  side  by  side  in  the 
same  viscus. 

CEETAIN     PATHOLOGICAL     APPEARANCES     COMMON     TO     BIL- 
HARZIOSIS OF  VISCERA  LINED   BY  MUCOUS  MEMBRANES. 

The  changes  about  to  be  described  may  be  found 
in  any  part  of  the  genito-urinary  tract  from  the  pelvis 
of  the  kidney  to  the  meatus  of  the  urethra ;  from  just 
beyond  the  duodenum,  along  the  whole  length  of  the 
intestinal  tract,  to  the  anus ;  and  from  the  vaginal 
orifice  to  the  internal  opening  of  the  cervical  canal 
of  the  uterus. 

General  swelling  and  infiltration  of  the 
mucous  membrane. — One  of  the  earliest  manifesta- 
tions of  bilharziosis  of  mucous  membranes  is  a  charac- 
teristic velvety  swelling  of  the  whole  thickness  of  the 
membrane.  The  surface  is  dark-red  in  colour  and  has 
the  appearance  of  a  "  thick  pile  velvet";  its  superficial 
layers  are  coated  with  a  viscid  tenacious  mucus  and, 
but  for  this  protection,  they  would  be  easily  rubbed 
off  on  the  least  friction.  The  mucous  membrane 
strips  off  easily  from  the  deeper  structures,  and  is  so 
much  swollen  and  thickened  as  to  be  thrown  into  folds. 
It  often  has  a  very  fine  brownish-yellow  powdery 
appearance  in  its  substance,  sometimes  throughout  its 
whole  extent,  but,  usually,  more  marked  in  some  parts 


20  BILEABZIOSIS. 

than  in  others,  and  is  very  vascular  throughout  its 
whole  thickness.  It  looks  almost  as  if  wet  sea-sand 
had  been  scattered  throughout  the  deeper  parts  of  the 
mucous  membrane.  It  is  easy  to  understand  that  any 
squeezing  of  this  soft,  friable,  vascular  mucous  mem- 
brane by  the  muscular  walls  behind  it,  as  in  the  act  of 
expelling  urine  or  faeces,  may  lead  to  a  rubbing  away 
of  the  surface  in  certain  parts  and  the  occurrence  of 
haemorrhage  from  the  eroded  area.      (Fig.   7.) 

In  some  cases,  scattered  irregularly  over  the  surface 
and  sown,  as  it  were,  on  the  softened  mucous  membrane, 
are  crops  of  small,  friable  papillomata,  like  large 
granules,  or  forming  elevated  ridges  of  swollen  tissue. 
This  condition  is  best  seen  in  the  rectum,  and  especially 
well  when  a  portion  of  the  mucous  membrane  is  pro- 
lapsed during  defalcation. 

The  change  in  the  mucous  membrane  must  take  a 
considerable  time  to  develop ;  for,  with  it,  the  rest  of 
the  wall  of  the  viscus  is  usually  much  thickened,  by 
hypertrophy  of  the  muscular  layer  and  the  formation 
of  bilharzial  fibrous  tissue  throughout  it. 

If  a  snip  of  this  infiltrated  mucous  membrane  be 
taken  and  a  smear  made  on  a  slide,  bilharzia  ova  will 
be  found.  A  section  of  the  wall  of  the  affected  viscus 
shows  the  mucous  membrane  swollen,  thickly  infiltrated 
throughout  with  leucocytes,  and  crowded  with  ova. 
These  are  densely  packed  in  the  deeper  parts  of  the 
epithelium  and  in  the  subjacent  tissue,  the  basement 
membrane  being  perforated  at  certain  points.  In  most 
places,  at  this  early  stage,  the  epithelial  lining  of  the 


PATHOLOGICAL   CHANGES.  21 

mucous  membrane  is  intact,  but  the  ova  raay  be  seen 
pushing  right  up  to  it,  and  they  soon  cause  a  necrotic 
melting  away  of  the  surface  cells.  By  the  excessive 
crowding  of  the  tissues  with  ova  and  cells  the  parts, 
in  spite  of  their  vascularity,  begin  to  lose  their  vitality 
and  a  molecular  disintegration  takes  place.  As  this 
process  involves  the  epithelial  layer  the  eggs  are 
shed,  together  with  small  round  cells,  degenerated 
epithelial  cells  and  blood  corpuscles.  By  the  crowd- 
ing of  the  ova  behind,  those  in  front  are  gradually 
pushed  towards  the  surface  and  are  shed  in  a  con- 
tinuous stream  as  soon  as  the  least  erosion  occurs. 

Looss  has  prepared  a  series  of  sections  which  show 
that  the  ova  may  even  escape  from  the  surface  of  a 
mucous  membrane  the  epithelial  layer  of  which  is 
quite  intact.  The  ova  are  seen  lying  between  the 
epithelial  cells  and  in  all  stages  of  their  passage 
through   the  epithelial  lining. 

The  fine  capillaries  and  veins  immediately  beneath 
the  epithelial  lining,  and  the  loose  connective  tissue 
in  which  they  occur,  are  also  filled  with  ova ;  while  in 
the  deeper  submucous  tissue  coupled  pairs  of  worms 
are  found  in  the  vessels.  In  the  muscular  coat  there 
may  be  collections  of  ova  with  an  occasional  couple  of 
worms  at  some  distance  from  them.  The  further 
appearances  vary  with  the  duration  of  the  disease ;  and 
on  this  will  also  depend  the  amount  of  small-celled 
infiltration  and  young  fibrous  tissue  that  will  be  present. 

Sandy  patches. — Another  comparatively  early 
change,  characteristic  of  bilharziosis  of  mucous  mem- 


22  BILHABZIOSIS. 

branes,  is  the  occurrence  of  brownish-yellow  sandy 
patches,  showing-  apparently  through  the  membrane, 
which,  over  these  areas,  is  thickened  and  dry.  The 
patch  appears  to  be  made  up  of  very  fine  grains,  not 
unlike  powdered  sulphur,  which  are  irregularly  grouped 
together  into  small  heaps  at  certain  points.  At  a  later 
stage  the  whole  mucous  membrane,  of  the  bladder 
particularly,  may  be  so  altered,  in  colour  and  structure, 
that  a  regular  calcified  lining,  which  gives  a  character- 
istic gritty  feeling  on  examination  with  a  sound,  is 
formed.  The  walls  of  the  affected  viscus  will  gener- 
ally be  found  much  thickened,  partly  from  muscular 
hypertrophy,  but  also  from  the  deposit  of  bilharzial 
fibrous  tissue  throughout  the  various  layers.  (Fig.  8.) 
On  cutting  into  such  a  sandy  patch  it  will  be  found 
hard,  thickened,  and  gritty,  and  the  tissue  easily  turns 
the  edge  of  the  razor  used  in  cutting  the  sections.  On 
miscroscopical  examination,  the  appearances  are  very 
similar  to  those  described  in  the  preceding  change ; 
except  that  there  is  much  more  hard  thickening  of  all 
the  parts  concerned  and  the  majority  of  the  ova  in 
and  under  the  epithelial  layer  are  calcified.  Deeper  in 
the  section  in  the  submucous  tissue  the  blood-vessels, 
especially  the  veins,  will  be  seen  dilated  and  varicose, 
and  pairs  of  worms  will  be  found  within  their  lumen. 
Looss  has  pointed  out  that  in  the  immediate  neighbour- 
hood of  the  worms  no  free  ova  are  found,  and  from  the 
position  of  the  worms  in  certain  serial  sections,  he  sug- 
gests that  the  female  stretches  out  her  thin  attenuated 
body  along  the  ultimate  radicles    of  the  submucous 


Fig.  8.— More  advanced  bilharziosis  of  the  bladder,  with  much  sandy 
change  and  considerable  thickening  of  the  coats  of  the  viscus.  Some 
small  papillomata  are  seen  on  the  posterior  wall. 


Fig.  9. — Bilharzial  papillomata  in  the  large  intestine. 

(From  specimens,  prepared  by  Professor  Summers,  in  the  Pathological 
Museum  of  the  School  of  Medicine,  Cairo.) 


PATHOLOGICAL   CHANGES.  23 

capillaries.  Having  stretched  herself  to  her  fullest  ex- 
tent, she  deposits  her  mature  ova  and  then  withdraws 
into  the  gynecophoric  canal  of  the  male,  of  which 
she  has  retained  hold  throughout  this  stretching  and 
depositing  process.  The  ova  thus  set  free  in  a  very 
fine  capillary  remain  where  they  have  been  placed, 
the  tissues  between  them  and  the  withdrawing  worm 
closing  in  again ;  thus,  a  considerable  interval  is  left 
between  the  depositor  and  her  deposit. 

Patchy  hyperaemia. — The  early  sandy  patches 
are  usually  associated  with  some  hyperaemia  of  the 
mucous  membrane  beyond  their  margins ;  but  this 
hyperaemia  may  sometimes  occur,  independently  of 
any  other  change,  as  quite  the  earliest  manifestation  in 
the  bilharzial  series.  This  is  altogether  different  from 
the  general  vascularity  of  the  mucous  membrane 
already  noticed.  In  these  hyperaemic  areas  the  mucous 
membrane  is  thickened  and  infiltrated  with  ova,  as 
in  other  early  manifestations,  and  around  them  and  in 
them  are  irregular  extravasations  of  blood. 

Bilharzial  vesicles. — In  some  cases  of  bil- 
harziosis  of  mucous  membranes  rounded  globules,  con- 
taining a  clear  or,  sometimes,  a  turbid  fluid  are  seen, 
like  small  blisters  on  the  epithelial  surface.  These 
globules,  which  are  superficially  covered  by  stretched 
and  flattened  epithelial  cells,  suggest  that  they  have 
their  origin  in  small  retention  cysts.  They  resemble 
closely  the  small  mucous  cysts  seen  in  the  buccal 
mucous  membrane,  and  probably  have  a  similar 
pathology. 


24  BILEABZIOSIS 

The  formation  of  papillomata. — In  certain 
cases  the  principal  change  is  one  of  proliferation  of 
epithelium.  Small  warty  outgrowths  may  be  seen 
arranged  quite  irregularly  over  the  mucous  membrane, 
sometimes  surrounded  by  a  zone  of  hyperseinia,  which 
varies  considerably  in  size  and  colour,  or  in  the 
midst  of  a  sandy  patch.  These  outgrowths  have  the 
structure  of  an  ordinary  papilloma,  the  central  very 
vascular  core  of  loose  connective  tissue  being  directly 
continuous  with  the  submucous  tissue,  in  which,  at 
the  extreme  base  of  the  papilloma,  a  coupled  pair  of 
worms  may  sometimes  be  found.  The  core  itself  is 
infiltrated  with  leucocytes,  in  which  lymphocytes  pre- 
dominate, and  numbers  of  ova  are  scattered  irregularly 
throughout  it.  It  will  be  noticed  that  in  certain  places 
the  ova  come  right  up  to  the  epithelial  covering  of 
the  papilloma.  In  some  parts  the  epithelium  has  the 
appearance  of  being  scooped  out  from  below;  while 
in  other  sections  the  surface  epithelium  is  entirely 
missing  and  the  ova  are  seen  streaming  out  from  the 
broken  surface.  The  epithelium,  often  very  delicate, 
as  the  fine  filaments  of  the  papillomata  are  so  thin,  is 
very  easily  shed,  and  thus  early  permits  of  secondary 
bacterial  invasion. 

The  papillomata,  which  are  of  all  conceivable 
shapes  and  sizes,  are  of  a  dark-red  colour,  fairly  firm 
in  consistence,  but  have  a  velvety  friable  surface ; 
but,  as  the  disease  progresses  and  the  surface  epi- 
thelium undergoes  necrosis,  they  become  granular 
and  shaggy  and  bleed  very  readily  on  the  least  fric- 


PATHOLOGICAL    CHANGES.  25 

tion.  In  the  blood  thus  discharged  ova  and  granular 
debris,  consisting  of  leucocytes,  degenerated  epithelial 
cells,  connective  tissue  cells  and  red  blood  corpuscles 
are  found.  Later,  the  papillomatous  change  becomes 
more  and  more  marked  and  there  is  no  limit  to  the 
diversity  of  form  or  size  of  the  individual  outgrowths. 
Very  often  a  bunch  of  papillomata  seems  to  sprout 
from  a  raised  plateau  of  thickened  mucous  membrane, 
and  these  papillomata  have  a  rather  bulbous  appearance 
at  their  extremities.  All  forms  may  give  off  secondary 
extremely  minute  papillae.  Leuckart  writes :  "One  may 
find  on  the  mucous  membrane  of  the  bladder  single  or 
grouped  excrescences,  not  unlike  condylomata,  with 
or  without  pedicles,  which  may  present  manifold 
variations  of  shape  and  may  be  as  large  as  a  bean. 
On  section,  the  mucous  membrane  is  thickened  and 
the  submucous  connective  tissue  hypertrophied. 
Both  are  pervaded  by  a  rich  network  of  capillaries, 
the  vessels  being  sometimes  dilated,  and  here  and 
there  changed  into  rather  large  cavities,  which  often 
contain  full-grown  specimens  of  the  bilharzia.  In  the 
parenchyma  of  the  excrescences,  which  is  formed 
chiefly  of  the  submucous  tissue,  numerous  eggs  are 
found."     (Fig.  9.) 

Sessile  masses. — In  other  specimens  the  papillo- 
matous formation  is  not  so  marked ;  but  irregular 
hummocks,  involving  often  a  considerable  extent  of 
the  mucous  membrane,  are  met  with.  These  masses 
form  irregular  raised  prominences,  which  may  en- 
croach upon  the  cavity  of  the  viscus  to  a  large  extent 


26  BILHARZIOSIS. 

and  sometimes  almost  fill  it.  They  are  very  vascular 
and,  have  the  structure  of  loose  fibrous  tissue  covered 
with  a  thickened  mucous  membrane,  which  is  infil- 
trated with  ova,  and,  at  first,  they  are  covered  with 
epithelium.  Later,  on  the  surface  of  the  elevations 
small  pits  and  finally  ulcers  may  form,  the  surface 
epithelium  having  necrosed,  exposing  a  richly  vascular 
and  highly  cellular  granulation  tissue.  The  whole 
viscus  affected  with  this  change  is  always  very  much 
thickened,  and  many  of  the  earlier,  more  superficial, 
changes  are  present  in  what  remains  of  the  mucous 
membrane.  Papillomata  and  sessile  masses  often 
occur  side  by  side  in  the  same  organ. 

Ulceration. — Sometimes  small  pits  may  be  found 
in  the  mucous  membrane  without  any  papillomatous 
or  sessile  changes.  These  may  be  scattered  over  the 
surface,  perhaps  in  the  midst  of  a  sandy  patch,  or, 
sometimes  as  the  principal  lesion  in  a  thickened,  in- 
filtrated bladder.  Then,  again,  ulcers  may  be  the 
second  stage  of  the  vesicular  formation  already  men- 
tioned, the  vesicle  bursting  and  a  minute  necrosis  of 
the  tissue  taking  place,  owing  to  the  obstructed  blood 
supply  caused  by  the  presence  of  ova  and  small 
celled  infiltration ;  in  other  cases  crevices  form  at  the 
base  of  papillomata  or  over  a  sandy  patch  and  ulti- 
mately form  ulcers.  At  a  later  stage  of  the  disease 
larger  and  more  definite  ulcers  may  form,  especially 
in  the  intestine.  They  are  produced  by  the  separ- 
ation of  a  papilloma  from  its  base.  A  distinct  ring 
of  necrosing  tissue  is  seen  round  the  pedicle,  and  the 


Fig.  10.— Ulceration  of  the  large  intestine,  resulting  from  the  sloughing 
off  of  bilharzial  papillomata  ("  bilharzial  dysentery"). 


Fig  11.— Extreme  case  of  bilharziosis  of  the  bladder  with  formation 
of  much  dense  scirrhusdike  tissue.  The  cavity  of  the  bladder  is 
almost  non-existent. 

(From    specimens,   prepared    by    Professor    Symmers,    in    the    PatholorjiccO 
Museum  of  the  School  of  Medicine,  Cairo.) 


PATHOLOGICAL   CHANGES.  27 

various  appearances  of  papilloma,  commencing  ne- 
crosis, partial  separation  and  finally  complete  separ- 
ation, with  the  formation  of  deeply-punched-out, 
gumma-like  ulcers,  can  be  studied  in  good  specimens. 
It  is  this  condition  of  late  ulceration  in  the  large 
intestine  which  is  most  commonly  responsible  for 
"  bilharzial  dysentery."     (Fig.  10.) 

Another  form  of  ulceration  is  met  with  in  the 
atrophic  types  of  bilharziosis.  This  finds  its  best 
illustration  in  bilharziosis  of  the  skin  and  subcutan- 
eous tissue,  in  connection  with  which  it  will  be  again 
referred  to. 

The  condition  of  the  structures  deep  to  the 
mucous  membrane  varies  considerably.  In  the 
early  stages  the  bilharzial  change  seems  to  affect 
mainly  the  mucous  and  submucous  coats,  with  but 
little  infiltration  of  the  muscular  coats  ;  but,  later,  the 
whole  organ  is  infiltrated.  The  change  deep  to  the 
submucous  coat  is,  as  elsewhere,  due  to  an  infiltra- 
tion of  small  cells  and  ova,  and  is  best  understood  by 
considering  it  the  formation  of  a  (bilharzial)  granu- 
lation tissue,  which  goes  through  all  the  changes  com- 
mon to  that  tissue.  The  tissue  thus  formed  varies 
considerably  in  density  and  extent. 

Thus  in  most  of  the  specimens  of  sandy  patches 
and  of  infiltration  of  the  mucous  membrane,  in  fact 
in  all  the  changes  already  described,  there  has  been 
some  thickening  of  the  visceral  walls,  either  local  or 
general.  In  many  cases  this  thickening  would  appear 
to  be  one  of  the  earliest  effects  produced  by  bilharzia ; 


28  BILHARZIOSIS. 

and  many  of  the  so-called  early  changes  occur  in  an 
organ  already  much  thickened  by  an  infiltration  not 
only  of  the  mucous  membrane  but  of  all  the  layers  of 
the  wall  of  the  viscus  deep  to  that  structure.  Even 
hypersemic  patches  are  often  seen  on  the  internal 
surface  of  a  thickened  bladder,  and  must  then  be 
only  a  manifestation  of  an  increase  in  an  irritation 
which  has  already  been  going  on  for  some  consider- 
able time.  In  fact,  one  can  best  judge  of  the 
chronicity  of  a  bilharzial  infection  in  a  hollow  organ 
by  the  thickness  of  the  walls  of  the  viscus  and  the 
degree  of  fibrous  transformation  of  its  surrounding 
tissues. 

Sometimes  a  very  hard  indurated  fibrous  mass  is 
produced  in  the  muscular  and  deeper  structures  of  the 
affected  viscus  ;  and  eventually  the  whole  essential 
structure  of  the  parts  is  completely  destroyed.  In 
such  cases  very  little  of  the  mucous  membrane  re- 
mains. In  certain  cases  a  mass  of  bilharzial  granu- 
lation tissue  appears  to  spread  inwards  and  makes  the 
cavity  of  the  organ  much  smaller,  in  much  the  same 
way  that  a  bone  with  congenital  syphilitic  changes,  by 
becoming  harder,  denser,  and  thicker  in  all  directions, 
eventually  almost,  if  not  completely,  obliterates  the 
central  medullary  canal  of  the  bone.  The  analogy  is 
a  good  one,  as  the  bilharzial  fibrous  tissue  is  often  a 
true  sclerosis.  Very  few  ova  are  found  in  this  hard 
tissue.  (Fig.  11.)  Sometimes  the  structure  of  this 
mass  resembles  that  of  a  scirrhous  cancer  with  ova 
lying  in  between  the  columns  of  epithelial  cells,  but 


Fig.  12.— Section  of  the  so-called  bilharzial  scirrhus  of  the  bladder. 
Numbers  of  ova  are  seen  lying  in  between  groups  of  epithelial 
cells. 

(From  a  specimen,  prepared  by  Professor  Summers,  in  the  Pathological  Museum 
of  the  School  of  Medicine,  Cairo.    Photo-micrograph  by  Mr.  F.  S.  Willmore.) 


PATHOLOGICAL   CHANGES.  29 

opinion  is  still  divided  as  to  the  true  significance  of 
this  aj)parently  cancerous  appearance.  (Fig.  12.) 

A  special  condition  in  which  the  connective  tissue 
of  the  meso-csecuni,  meso-colon,  and  meso-rectum  is 
densely  infiltrated,  is  seen  in  certain  cases  of  bil- 
harziosis  of  the  large  bowel,  and  will  be  referred  to  in 
a  later  section. 

The  extreme  variety  in  the  pathological  manifesta- 
tions, and  their  great  diversity  of  form,  is  probably 
to  be  explained  by  repeated  re-infection,  to  which  the 
patients  must  be  constantly  subject,  living,  as  they 
do,  always  amidst  the  same  unfavourable  conditions. 
Indeed  short  of  a  complete  exile  from  Egypt  the 
affected  person,  usually  an  agricultural  labourer,  can 
hardly  get  away  from  the  risk  of  re-infection.  The 
multiplicity  of  the  lesions,  due  to  a  new  beginning 
being  constantly  made  in  the  series  of  pathological 
changes,  is  thus  not  difficult  to  understand. 


III. 

BILHARZIOSIS   OF    THE   URINARY   SYSTEM. 

A  vaeiety  of  interstitial  nephritis  of  bilharzial  origin 
has  been  described,  and  bilharzia  ova  have  been  found 
in  the  substance  of  the  kidneys  by  Kartulis  and  others. 
Papillomatous  growths  occur  in  the  pelvis  of  the  kid- 
ney; and  both  the  hypertrophic  and  the  atrophic  forms 
of  the  disease  are  met  with  in  the  ureters ;  but  the 
bladder  is  by  far  the  most  common  seat  of  bilharzi- 
osis.  It  is  probable  that  the  disease  here,  as  in  other 
organs,  is  only  one  of  the  local  manifestations  of 
bilharziosis,  and  not  a  centre  from  which  extension 
takes  place,  by  contact  or  proximity  of  tissue,  to  other 
parts  of  the  urinary  tract  in  communication  with  it. 
Infection  of  a  part  by  bilharzia  is  due  to  a  centrifugal 
distribution,  the  centre  being  the  blood  in  the  portal 
vein  and  its  tributaries,  and  there  is  no  local  propaga- 
tion of  the  worms  in  the  tissues.  Each  manifestation 
is  due  to  the  local  effect  of  certain  couples,  or  colonies 
of  couples,  and  the  effects  are  limited  by  the  extent 
of  surface  or  area  over  which  each  couple  is  able  to 
disseminate  its  ova.  Large  areas  of  disease  are  due 
to  the  combined  action  of  many  couples  working  side 
by  side,  each  taking  charge  of  a  particular  area  for 
destruction. 

30 


BILHAEZIOSIS  OF  THE    URINARY  SYSTEM.  31 

Bilharziosis  of  the  bladder. — The  general  swell- 
ing and  infiltration  of  the  mucous  membrane,  described 
in  some  detail  in  the  preceding  section,  is  probably 
the   earliest   manifestation   we  know   and  recognise, 
and  this  condition  is  seen  at  its  best  in  the  bladder. 
Photographs  and  drawings  fail  to  give  an  adequate 
idea  of  this  very  characteristic  appearance  with  its 
wet    sea-sand   scattered    about   in   the   substance    of 
the   swollen    membrane,    and,    it    may    be,    thickly 
infiltrating   the    whole     of    the    prostate.     (Fig.    7.) 
In  the   fresh    state   such  a  surface  is  thinly  coated 
with   a   peculiarly   tenacious    mucus,    in    which    ova 
may   be   found,   and   which   appears   to  be   a   great 
protection  to  the  membrane.     Were  the  surface  bereft 
of   this    slippery  mucus  and  dry,  it  would  be  very 
friable  and  easily  abraded  by  the  least  friction.     As  it 
is,  it  is  not  until  the  sandy  change  becomes  marked 
that  the  surface  of  the  mucous  membrane  becomes  dry, 
harsh,  and  thickened.      This  may  occur  to  such  an 
extent  that  the  internal  lining  of  the  bladder  comes 
to  resemble  a  cyst  wall  which  has  undergone  an  almost 
general  calcification.     The  surface  has  then  the  appear- 
ance of  being  coated  with  much  dry  sun-baked  sand, 
as  opposed  to  the  earlier  appearance  of  wet  sea-sand, 
which  is  definitely  deep  within  the  substance  of  the 
mucous  membrane.     (Fig.   8.) 

Another  change  is  a  patchy  hyperemia  associated 
with  minute  extravasations,  either  as  an  independent 
manifestation,  or  in  an  already  thickened  and  in- 
filtrated mucous  membrane.     This  may  be  confined  to 


32  BILHARZIOSIS. 

the  region  of  the  trigone  or  scattered  irregularly  over 
the  posterior  surface  of  the  bladder.  On  these  hy- 
perseniic  patches  in  the  substance  of  a  swollen  mucous 
membrane,  or  as  quite  distinct  lesions  in  themselves, 
may  be  larger  or  smaller  dry  sulphury  sandy  patches. 
These  have  the  general  characters  already  described 
and  map  out  definite  areas,  which  are  irregularly  dis- 
tributed over  the  surface  of  the  bladder  upon  thickened 
patches  of  the  mucous  membrane.  As  the  disease  pro- 
gresses, larger  and  larger  areas  become  affected,  and  as 
adjoining  patches  unite,  the  thickened  internal  lining 
of  the  organ  becomes  hard  and  on  section  grates  under 
the  knife,  not  only  from  the  presence  of  calcified  ova  in 
the  mucous  membrane,  but  also  from  the  granular 
phosphatic  deposit  which  has  occurred  on  its  surface. 
At  the  same  time  the  associated  thickening  increases 
and  soon  involves  all  the  coats  of  the  bladder,  until 
the  viscus  resembles  a  calcified  cyst,  with  thickened 
walls.  "  As  the  patches  increase  in  size,  they  also 
increase  in  thickness,  owing  to  the  overgrowth  of  the 
surrounding  tissue,  due  to  the  irritation  of  the  presence 
of  the  eggs,  and  also  to  the  fact  that  Nature,  striving 
to  undo  the  mischief  she  has  permitted  for  the  sake  of 
the  propagation  of  the  bilharzia  species,  tries  to  render 
the  eggs  harmless  within  the  host  by  enveloping  them 
in  fibrous  tissue  and  isolating  them,  as  she  does  to 
foreign  bodies  embedded  in  living  tissue  elsewhere." 
(Milton.) 

Sometimes  a  row  of  bilharzial  vesicles   makes  a 
border  round  the  trigone,  or  a  few  tiny  warty  projec- 


BILHARZIOSIS   OF  THE    URINARY  SYSTEM.  33 

tions  occur  in  the  same  situation,  with  or  without  the  so- 
called  earlier  manifestations.  As  has  already  been 
pointed  out,  these  changes  frequently  occur  in  an 
already  much  thickened  and  generally  hypersemic 
bladder  ;  and  before  the  sandy  patches  have  had  time 
to  develop,  considerable  general  infiltration  of  the 
whole  thickness  of  the  bladder  with  ova  and  small 
round  cells  has  been  going  on.  The  calcification  of  the 
ova,  which  is  the  principal  change  in  the  sandy  patch, 
takes  at  least  a  year  to  develop. 

From  the  early  stages  in  the  pathological  changes 
above  described  onwards,  the  different  forms  of  bil- 
harzial  lesions  are  very  much  mixed ;  and  it  is  difficult 
to  present  the  progress  of  the  disease  in  anything  like 
regular  order.  In  almost  every  infected  bladder  all  or 
many  of  the  different  manifestations  are  to  be  found, 
in  greater  or  less  degree,  but  the  principal  change  is 
that  of  marked  epithelial  proliferation  and  the  forma- 
tion of  papillomata.  The  papillomata,  the  general 
structure  of  which  has  already  been  described,  occur 
in  many  shapes,  from  the  fine  villous  form  to  the  large 
bulbous-ended  variety.  It  is  not  at  all  unusual  to  find 
a  bunch  of  fine  papillomata  sprouting  from  a  small 
raised  plateau  of  thickened  mucous  membrane.  Even 
at  this  early  stage,  there  is  much  more  firmness  about 
a  bilharzial  papilloma  than  in  an  ordinary  soft  fibrous 
or  myxomatous  polypus.  The  bilharzial  papillomata 
are,  however,  very  friable  and  bleed  readily  in  ad- 
vanced cases  ;  and,  at  times,  become  so  soft  as  to  form 
large  shaggy  masses,  with  a  fleecy  surface,  growing  in 


34  BILHARZIOSIS. 

clusters  from  the  wall  of  the  bladder.  The  papillomata 
have  a-  special  predilection  for  the  trigone  and  the 
posterior  surface  generally ;  but  after  a  time  they  are 
seen  widely  distributed  over  the  mucous  membrane. 
So  profuse  may  be  the  growth  of  papillomata  that 
almost  the  whole  cavity  of  the  bladder  may  be  filled 
with  them,  and  as  concurrently  there  is  an  increase  in 
the  thickness  of  the  bladder  wall,  the  actual  reservoir 
space  becomes  very  small  indeed.  In  other  cases, 
sessile  masses,  not  unlike  condylomata,  but  much 
firmer  and  extensive,  form  the  prominent  features  of 
the  bilharzial  changes.  These  elevations  are  of  various 
sizes  and  shapes  and  are  usually  associated  with  con- 
siderable papillomatous  formation  also.  They  consist 
of  a  loose  fibrous  tissue  foundation,  capped  with 
much  thickened  infiltrated  mucous  membrane.  Their 
structure  is  thus  similar  microscopically  to  a  papil- 
loma and  they  undergo  exactly  the  same  secondary 
changes. 

Another  change,  which  must  begin  very  early,  is 
thickening  of  the  coats  of  the  bladder  from  the  irrita- 
tion of  the  bilharzia  worms  and  their  ova.  This  in- 
volves all  the  coats  of  the  bladder,  and  the  organ  is  to 
all  appearances  like  an  hypertrophied  organ  resulting 
from  some  chronic  obstruction  to  the  outflow  of 
urine.  There  is  some  true  hypertrophy  of  the  muscu- 
lar coat  from  overwork,  due  to  the  increased  frequency 
of  micturition,  the  obstruction  to  the  outflow,  and  the 
straining  entailed  in  emptying  the  bladder,  but  quite 
as  much,  if  not  more,  of  the  thickening  is  due  to  the 


BILRARZIOSIS   OF  THE   URINARY  SYSTEM.  35 

formation  of  bilharzial  granulation  tissue  and  its  subse- 
quent transformation  into  fibrous  tissue.  The  prostate 
is  often  found  infiltrated,  as  are  also  the  vesicular 
seminales,  which,  in  advanced  cases,  are  almost  lost 
in  a  fibrous  mass,  that  is  welding  the  base  of  the 
bladder  to  the  surrounding  connective  tissue.  There 
is  not  usually  much  enlargement  of  the  prostate,  as  here 
the  atrophic  form  of  the  disease  is  most  commonly 
found,  and  contraction,  rather  than  proliferation  of  the 
new  tissue,  is  the  rule.  In  later  stages,  any  true  pros- 
tatic symptoms  that  may  be  present  are  masked  by  the 
presence  of  cystitis,  stone,  etc. 

Probably  the  most  usual  condition  of  the  bladder 
in  severe  bilharziosis  is  as  follows  : — The  bladder  in- 
ternally is  thickly  infiltrated  with  extensive  patches  of 
dry  sandy  change,  so  that  portions  of  the  wall  are 
almost  entirely  converted  into  a  calcified  plate ;  or  it 
is  filled  with  papillomata  of  various  sizes  and  shapes, 
very  irregularly  distributed  throughout  the  mucous 
membrane.  The  walls  of  the  bladder  are  much 
thickened  and  infiltrated,  and  the  cavity  is  considerably 
contracted.  From  this  thickening  and  the  presence  of 
the  papillomatous  masses  the  actual  urine  space  is  very 
small,  and  the  cavity  is  often  eccentrically  placed. 
"  Owing  also  to  the  calcification  of  the  bladder  wall 
the  effect  of  muscular  contraction  is  largely  lost,  and 
the  bladder  is  more  like  a  dilatation  in  a  firm-walled 
tube  than  a  cavity  in  a  contractile  organ "  (Milton). 
The  prostate  is  infiltrated  throughout  with  calcified 
ova,   and  may   be   somewhat   enlarged.      The   urine 


36  BILHARZIOSIS. 

collects  in  the  depressions  between  the  papillomatous 
masses  and  decomposition  readily  occurs,  so  that  the 
surface  of  the  masses  and  the  mucous  membrane 
generally  may  be  thickly  coated  with  phosphates ; 
and,  owing  to  obstruction  at  their  orifices,  the  ureters 
become  dilated  and  hydronephrosis  with  all  its  con- 
secutive and,  later,  septic  consequences  soon  results. 

Other  cases  are  seen  with  enormous  thickening, 
deep  to  the  mucous  membrane,  extending  throughout 
all  the  coats  of  the  bladder.  This  has  a  section  like 
caseous  tissue,  or  may  be  quite  fleshy,  like  sarcoma. 
In  some  instances  there  is  only  a  very  narrow  slit  left 
as  a  representative  of  the  bladder  cavity.  What 
remains  of  the  mucous  membrane  is  dark,  ragged,  and 
degenerated,  and  shows  the  remains  of  papillomata. 
(Fig.  13.) 

Another  fairly  common  change  of  the  same  kind 
consists  in  the  formation  of  an  exceedingly  soft  mass 
of  tissue,  often  with  the  consistence  and  colour  of 
softened  brain  matter.  This,  which  usually  springs 
from  a  considerable  area  of  the  mucous  surface,  may 
almost  completely  occupy  the  cavity  of  the  viscus. 
It  is  not  uncommon  to  find  that  the  remainder  of  the 
cavity  is  filled  with  recent  blood  clot  and  fragments 
of  necrosed  tissue  from  the  surface  of  the  mass. 

As  the  thickening  of  the  bladder  proceeds,  it  comes 
to  be  felt  as  a  hard  mass  above  the  pubis,  and  it  may 
increase  to  such  an  extent  as  to  reach  almost  to  the 
umbilicus,  with  or  without  infiltration  of  the  abdominal 
wall.     In  other  cases  the  thickening  is  not  so  much  of 


Fig.  13. — Advanced  bilharziosis  of  the  bladder.  The  narrow  crescentic 
area  below  and  to  the  left  represents  all  that  remains  of  the  cavity 
of  the  viscus. 

(From  a  specimen,  'prepared  by  Professor  Symmers,  in   the   Pathological 
Museum  of  the  School  of  Midicine,  Cairo.) 


BILHARZIOSIS  OF  TEE   URINARY  SYSTEM.  37 

the  bladder  itself,  but  involves  all  the  loose  connective 
tissue  round  it  and  the  adjacent  organs.  The  most 
usual  site  of  this  change  is  anteriorly,  whence  it  extends 
into  the  structures  of  the  abdominal  wall.  The 
following  case  illustrates  this  condition  very  well : 
The  patient  was  a  young  woman,  who  gave  a  four 
months'  history  of  a  tumour  in  the  lower  part  of  the 
abdomen,  associated  with  painful  micturition  for  some 
time  preceding  the  appearance  of  the  swelling.  A 
lump  was  found  above  the  pubis,  extending  upwards 
almost  to  the  umbilicus  and  laterally  to  each  semilunar 
line.  The  mass  was  of  stony  hardness,  and  running 
into  its  substance  were  two  unhealthy-looking  sinuses, 
which  did  not,  so  far  as  could  be  made  out,  communi- 
cate with  the  bladder.  There  was  not  the  least 
tenderness  on  examination  or  pain,  the  only  incon- 
venient symptom  being  marked  frequency  of  micturi- 
tion, which  was  explained  by  the  discovery  of  a 
large  stone  in  the  bladder.  The  vagina,  uterus  and 
urethra  were  quite  healthy,  and  the  urine  contained  no 
ova.  An  incision  was  made  in  the  middle  line  through 
the  hard  mass  and  exposed  the  wall  of  the  bladder, 
which  was  thickened  with  bilharzial  tissue,  especially 
at  the  apex.  The  bladder  was  opened  and  a  large 
ovoid  stone  removed.  The  bulk  of  the  tumour  was 
in  front  of  the  bladder,  and  the  sinuses  ran  down 
through  the  mass  to  a  space  full  of  soft  degenerated 
bilharzial  tissue,  just  above  the  apex  of  the  viscus. 
The  whole  thickness  of  the  abdominal  wall  was  infil- 
trated with  the  growth,  in  which,  except  for  a  few 


38  BILHARZIOBIS. 

fibres  of  the  rectus  muscle,  nothing  but  a  fibrous 
structure  could  be  made  out. 

Microscopically  the  growth  consisted  of  firm  white 
fibrous  tissue,  in  which  no  ova  could  be  found.  The 
opening  in  the  bladder  gradually  closed,  and,  though 
the  tumour  remained  as  before,  considerable  relief 
was  experienced  by  the  removal  of  the  stone. 

There  is  still  considerable  discussion  as  to  the 
nature  of  these  hard  masses  produced  by  bilharzia. 
Some  would  have  one  believe  that  they  are  all  cancer- 
ous, the  exciting  cause  of  the  malignant  change  being 
bilharzia  ova ;  but,  certainly,  most  of  them  are  simply 
masses  of  dense  fibrous  tissue,  practically  scar  tissue, 
the  density  being  specially  marked  owing  to  the 
essentially  chronic  nature  of  the  inflammatory  process. 
There  are,  however,  cases  of  apparently  typical  scir- 
rhus  cancers  in  connection  with  bilharzial  changes  in 
the  bladder,  and,  in  such,  microscopic  section  shows 
the  ova,  often  in  very  large  numbers,  lying  between 
the  masses  of  cancer  cells.  (See  Fig.  12.)  Clinically 
there  is  very  little  to  help  in  the  differential  diagnosis 
of  these  bilharzial  fibrous  masses  from  those  really 
cancerous,  though  sometimes  a  secondary  enlarge- 
ment of  neighbouring  glands  and  the  extreme  rapidity 
of  growth  are  in  favour  of  cancer.  "  The  co -existence 
of  carcinoma  and  bilharzia  is  generally  regarded  as 
fairly  common,  but,  I  think,  it  does  not  in  reality 
occur  so  frequently  as  some  writers  would  lead  one 
to  expect."     (Milton.) 

Occasionally  sinuous  fistulous  tracks,    lined  with 


BILHARZIOSIS  OF  TEE   URINARY  SYSTEM.  39 

bilharzial  granulation  tissue,  form  in  the  hard  masses, 
whether  carcinomatous  or  not,  and,  communicating  by 
means  of  a  narrow  opening  with  the  bladder  below, 
discharge  a  small  amount  of  filthy  urine,  pus  and 
granular  debris  on  the  skin  surface.  These  fistulas 
in  the  midst  of  hard  tissue  are  specially  found  in  the 
suprapubic  region,  sometimes  opening  at  the  um- 
bilicus, or  in  the  perinseum.  In  the  umbilical  fistulse 
a  track  runs  down  between  the  muscles  of  the  an- 
terior wall  of  the  abdomen  and  the  peritoneum,  and 
ends  in  a  soft  degenerated  mass  round  the  upper  part 
of  the  bladder,  but  without,  apparently,  opening  into 
it.  This  degenerated  mass  is  found  in  the  prevesical 
and  lateral  vesical  spaces,  while  the  bladder  walls  are 
thickened  and  severely  affected  with  bilharzia,  but 
there  is  no  direct  communication  between  the  lesions 
within  and  without  the  bladder.  It  seems  as  if  these 
cases  begin  as  a  bilharzial  infiltration  of  the  loose 
connective  tissue  round  the  bladder  in  front,  which 
ultimately  makes  for  the  umbilicus  along  the  urachus 
in  the  lines  of  least  resistance. 

Rarely,  an  enormous  proliferating  mass  may  burst 
through  the  walls  of  the  bladder  and  present  in  the 
peritoneal  cavity  where,  once  leakage  of  urine  has 
taken  place,  fatal  peritonitis  rapidly  ensues. 

The  secondary  backworking  effects  of  bilharziosis 
of  the  bladder  on  the  ureters  and  kidneys  are 
in  no  way  different  from  those  produced  by  any 
other  obstruction  to  the  outflow  of  urine ;  indeed,  the 
dilatation  of  the  ureters  and  the  pelvis  of  the  kidney, 


40  BILHARZIOSIS. 

due  often  to  blocking  of  the  vesical  orifice  of  the 
ureter,  »may  almost  be  considered  the  natural  conse- 
quences of  bilharziosis  of  the  bladder,  since  so  much 
obstruction  to  the  outflow  of  urine  is  offered  by  the 
many  lesions  in  that  viscus.  Further,  the  ureter 
itself  is  not  unfrequently  the  seat  of  bilharzial  changes, 
papillomata  and  a  general  infiltration  of  the  mucous 
membrane  being  the  most  common  lesions,  and  thus, 
quite  apart  from  any  assistance  rendered  by  the 
bladder,  considerable  hydronephrotic  changes  may  be 
produced.  One  never  finds  these  mechanical  changes 
in  ureters  and  kidneys  without  also  a  septic  infection, 
arising  from  the  condition  into  which  the  bladder 
passes  after  the  onset  of  cystitis.  A  rapidly  spread- 
ing septic  inflammation  is  soon  developed  and  ex- 
tends not  only  to  the  ureters  and  the  pelvis  of  the 
kidneys,  but  also  into  the  substance  of  the  latter  organ, 
with  all  the  severest  accompaniments  of  the  worst  type 
of  septic  surgical  kidney.  "  When  it  happens,  as  is  so 
frequently  the  case,  that  the  contents  of  the  bladder 
are  represented  by  a  collection  of  decomposing  organic 
tissue  and  stinking  urine,  the  step  to  a  septic  inflam- 
mation of  ureters  and  kidneys,  from  simple  dilatation 
of  the  ureters  and  hydronephrosis,  is  easily  taken." 
(Milton.)  On  the  other  hand,  severe  symptoms  may 
sometimes  be  produced  by  apparently  insignificant 
manifestations.  Thus  one  has  seen  an  autopsy  on  a 
case  of  marked  double  hydronephrosis  in  which  the 
causal  lesions  were  two  small  bilharzial  papillomata 
at  the  vesical  openings  of  both  ureters. 


BILHARZ10SIS   OF  THE   URINARY  SYSTEM.  41 

The  very  frequent  association  of  bilharziosis  of  the 
bladder  and  of  the  urethra  will  be  again  referred  to. 

Early  symptoms  of  bilharziosis  of  the 
bladder. — The  very  earliest  pathological  manifesta- 
tions of  bilharziosis  do  not  appear  to  give  rise  to  any 
symptoms  for  a  considerable  time;  but,  as  the  infil- 
tration and  swelling  of  the  mucous  membrane  progress, 
the  softening  of  the  surface  layers  of  the  epithelium 
increases,  probably  from  the  irritation  of  the  urine,  as 
well  as  from  the  gradual  molecular  disintegration  due 
to  the  bilharzial  process,  and  a  centre  of  irritation  is 
produced ;  and  that,  usually,  in  the  naturally  most 
sensitive  portion  of  the  bladder,  the  trigone.  This 
will  give  rise  to  some  increased  frequency  in  micturi- 
tion and,  perhaps,  a  feeling  of  heat  in  the  perinseum 
or  the  rectum,  or  along  the  course  of  the  urethra. 
Further,  in  the  attempt  to  get  rid  of  the  irritant,  that 
is,  to  expel  the  urine  from  the  irritated  trigone,  an 
increased  straining  occurs  at  the  end  of  the  act  of 
micturition.  If  a  small  piece  of  the  swollen  vascular 
mucous  membrane  becomes  nipped  between  the  con- 
tracted muscular  bands  of  the  wall  of  the  bladder, 
some  hsematuria  may  be  present,  especially  at  the 
end  of  micturition.  "  The  amount  of  blood  lost  is,  as 
a  rule,  insignificant,  and  would  probably  never  be 
noticed  by  the  patient  if  it  were  mixed  with  the  urine 
as  it  is  passed ;  but  the  peculiarity  of  this  haemorrhage 
is  that  the  few  drops  of  blood  which  are  lost  are  voided, 
either  with  the  last  few  drops  of  urine,  or  else  escajDe 
from  the  urethra  after  the  act  of  micturition  is  alto- 


42  BILHABZIOSIS. 

gether  finished ;  whereby  the  attention  of  the  patient 
is  caught  by  the  marked  difference  in  the  appearance  of 
the  last  part  of  the  evacuated  fluid.  In  a  large  number 
of  cases  hsematuria  begins  without  any  subjective  symp- 
toms ;  but,  as  a  rule,  soon  after  the  patient  notices  the  loss 
of  blood,  he  begins  to  complain  of  pricking  or  scalding 
in  the  urethra  during  micturition,  together  with  a  sense 
of  pain  or  weight  in  the  perinseum."  (Milton.)  This 
state  of  irritation,  much  of  which  may  be  due  to  an 
early  infiltration  of  the  prostate,  with  occasional 
haematuria,  may  persist  for  a  long  time  before  any 
more  definitely  characteristic  symptoms  appear  ; 
indeed,  many  cases  go  no  further  than  this  for  several 
years. 

The  signs  above  noted  may  be  so  slight  that  the 
possibility  of  bilharzia  as  a  cause  may  not  have  been 
considered.  Nothing  can  be  made  out  on  abdominal 
examination  except,  perhaps,  some  tenderness  on  deep 
pressure  just  above  the  symphysis  pubis.  Examina- 
tion with  a  finger  in  the  rectum  and  a  sound  in  the 
bladder  may  disclose  distinct  thickening  of  the 
bladder  wall  and,  perhaps,  some  enlargement  of  the 
prostate,  which  may  also  be  tender.  On  introducing 
the  sound  it  usually  passes  without  difficulty,  but 
there  may  be  considerable  pain  as  the  point  of  the 
instrument  enters  the  bladder.  The  mucous  membrane 
may  feel  soft  and  swollen  but,  at  this  early  stage,  no 
roughness  of  the  wall  will  be  felt  except,  at  times, 
posteriorly  where  the  mucous  membrane  is  thrown 
into  ridges  and  feels  harder  than  in  other  situations. 


EILHARZIOSIS   OF  THE   URINARY  SYSTEM.  43 

Early  papillomata  or  warty  projections  are  difficult  to 
feel  with  the  sound,  but  a  bunch  of  them  may  some- 
times be  made  out  in  the  region  of  the  trigone.  On 
the  withdrawal  of  the  sound  a  small  quantity  of  blood 
may  escape  from  the  urethra  or  be  passed  with  the 
next  urine. 

If  there  are  other  symptoms  pointing  to  the  pos- 
sibility of  bilharziosis  these  local  signs  may  be  dis- 
covered when  one  is  on  the  look-out  for  them,  but  they 
are  often  so  indefinite  that  they  may  very  easily  be 
missed  in  an  ordinary  routine  examination  of  the 
bladder.  The  urine  is  acid  and  clear,  except  at  the 
very  end  of  micturition,  when  some  thick  tenacious 
mucus  may  be  passed  with  it.  Repeated  examina- 
tions, especially  of  the  deposit  of  the  whole  day's 
urine  (if  necessary,  after  centrifugalising  the  deposit), 
may  reveal  the  presence  of  ova,  which  at  once  con- 
firms the  diagnosis.  The  ova  are  much  more  likely 
to  be  found  if  hsematuria  is  present,  especially  if  the 
last  few  drops  of  urine  are  examined.  Obviously  if 
there  is  hsematuria  the  urine  will  contain  a  small 
amount  of  albumen  and  blood  corpuscles. 

Certain  cases,  even  when  there  is  an  early  for- 
mation of  papillomata,  present  no  symptoms  whatever 
except  painless  hsematuria,  varying  in  amount  and 
coming  somewhat  irregularly,  especially  with  the  last 
squeeze. 

In  these  early  stages,  the  general  health  does  not 
suffer  to  any  appreciable  extent ;  but  after  a  time  the 
constant  haemorrhage,  insignificant  in  amount  though 


U  BILHAEZIOSIS, 

it  may  be,  gives  rise  by  its  persistence  to  anaemia, 
with  all  its  usual  accompaniments.  In  all  anaemias  in 
Egypt  the  presence  of  ankylostoma  must  also  be 
suspected  and  search  made  accordingly  for  ova  in 
the  fasces. 

It  is  not  at  all  uncommon  to  find  ankylostoma  and 
bilharziosis  associated  in  the  same  patient. 

In  a  somewhat  more  severe  case  the  symptoms  will 
present  an  aggravation  of  those  already  described,  but 
are  still,  mainly,  irregular  haematuria  and  some  in- 
creased frequency  of  micturition.  The  urine  will  con- 
tinue to  be  acid,  fairly  clear  at  most  times  but  contain- 
ing blood  and  mucus  at  the  end  of  micturition.  To 
examine  such  urine  for  ova  the  whole  quantity  passed 
in  the  t  tventy-four  hours  should  be  taken  and  allowed  to 
settle  in  a  conical  glass.  The  supernatant  fluid  is 
drawn  off,  as  soon  as  a  good  deposit  has  formed,  and 
a  small  quantity  of  the  residue  taken  off  in  a  pipette 
and  placed  on  a  slide.  The  specimen  will  contain, 
besides  the  usual  constituents,  blood  corpuscles, 
epithelial  cells,  small  round  cells,  connective  tissue 
cells,  amorphous  masses  and  granular  debris,  pus 
cells  and  ova.  The  ova  have  the  spine  at  the  end,  and 
contain  either  living  or  dead  miracidia.  Often  the 
contents  of  the  ova  are  a  granular  debris  or  a  calcified 
mass.  (See  Fig.  3.)  The  ova  which  contain  living 
miracidia  are  clear  and  more  or  less  transparent  and 
with  high  powers  the  structure  of  the  miracidia  may 
be  clearly  made  out. 

Ova  are  sometimes  found  in  the  spermatic  fluid 


BILHARZIOSIS   OF  THE    URINARY  SYSTEM.  45 

(Lortet  and  Vialleton),  especially  in  cases  in  which  the 
vesiculse  seminales  are  affected. 

Sooner  or  later  the  urine  becomes  decomposed,  as 
will  be  readily  understood  when  the  condition  of  the 
bladder  is  recalled,  and  all  the  symptoms  of  acute 
cystitis  set  in.  There  is  nothing  to  distinguish  this 
form  of  cystitis  from  any  other  except  the  almost  con- 
stant hematuria  and  the  presence  of  bilharzia  ova 
in  the  urine.  Once  cystitis  has  started  the  patient  is 
practically  never  free  of  it,  though  after  a  time  the 
acuteness  of  the  condition  passes  off  and  a  steady 
chronic  form  persists.  The  urine  will  now  be  alkaline, 
turbid,  offensive,  dark-brown  in  colour  from  the  blood 
in  it,  and  will  contain  mucus,  pus,  albumin,  phos- 
phates, granular  debris,  epithelial  cells,  blood  cor- 
puscles and  ova,  the  latter  in  great  numbers.  At  a 
late  stage  the  ever-present  symptoms  of  cystitis  and 
the  almost  constant  micturition,  from  the  irritation 
within  and  the  small  size  of  the  cavity  of  the  bladder, 
the  pain  and  scalding  in  the  urethra  during  the 
passage  of  urine,  the  pain  above  the  pubis,  in  the 
perinseum  and  in  the  rectum,  the  latter  often  with  a 
great  deal  of  tenesmus,  soon  make  the  patient's  life  an 
absolute  misery  to  himself.  He  gets  very  little  rest  at 
night  and  it  is  difficult  to  imagine  even  an  Egyptian 
allowing  this  condition  to  go  on  without  any  attempt 
at  treatment,  yet  such  is  constantly  the  case. 

The  bladder  condition  may  become  at  any  time 
still  further  aggravated  by  the  deposit  of  phosphates 
on  the  abraded  mucous  membrane  or  on  the  ragged 


46  BILEABZIOSIS. 

tops  of  papillomata  or  sessile  masses.  The  whole 
interior  of  the  bladder  may  be  thickly  crusted  with 
these  phosphatic  masses,  which  go  on  increasing  as 
the  cystitis  persists  and  the  urine  is  always  alkaline. 
Pieces  of  these  incrustations  may  break  off  and  form 
the  nucleus  of  phosphatic  stones,  thereby  greatly  in- 
creasing the  patient's  misery.  These  stones  are  a 
frequent  accompaniment  of  bilharziosis  of  the  bladder, 
and  are  formed  in  exactly  the  same  way  as  a  stone 
forms  on  any  other  foreign  body  in  this  organ.  A 
great  many  stones  are,  however,  met  with  in  bil- 
harzial  bladders  which  consist  of  uric  acid  or  oxalate 
of  lime,  with,  sometimes,  alternating  layers  of  phos- 
phates. Such  stones  must  form  originally  in  acid 
urine,  that  is,  before  it  has  become  alkaline  and  there 
has  been  any  deposit  of  phosphates.  Renal  colic  is 
comparatively  uncommon  in  Egypt,  and  it  would 
seem  probable  that  many  uric  acid  stones  form  in  the 
bladder  on  a  nucleus  of  bilharzial  ova  or,  more  prob- 
ably, upon  a  small  piece  of  a  papilloma,  in  a  bladder 
in  which  the  urine  is  still  acid,  the  occasional  layer 
of  phosphates  being  formed  when  a  mild  attack  of 
cystitis  has  supervened  and  subsequently  yielded  to 
treatment.  The  average  Egyptian  pays  so  little  at- 
tention to  the  comparatively  severe  symptoms  of  bil- 
harziosis and  the  cystitis  with  it  that,  as  soon  as  the 
stone  is  removed,  he  will  never  consent  to  remain  in 
hospital  for  further  treatment  of  the  original  bladder 
condition. 

The  conditions  found   on   abdominal,    rectal,    or 


BILEABZIOSIS   OF   THE    URINARY  SYSTEM.  47 

combined  examination,  and  also  with  the  sound,  will 
vary  with  the  pathological  changes  within  the  viseus 
and  in  its  immediate  neighbourhood.  Many  of  the 
grosser  lesions,  such  as  tumour  masses,  sandy  patches, 
concretions,  and  stones,  can  be  felt  with  a  sound,  and 
the  extent  and  contour  of  the  bladder  cavity  and  the 
thickness  of  the  walls  determined.  Especially  must 
a  careful  search  be  made  for  stone,  the  presence  of 
which  may  be  the  cause  of  the  marked  severity  of 
the  symptoms.  Considerable  difficulty  in  the  intro- 
duction of  the  sound  may  sometimes  be  experienced, 
owing  to  the  implication  of  the  urethra  in  the  bil- 
harzial  process,  and  the  presence  of  stricture,  which 
occurs  in  one  variety  of  urinary  fistula. 

In  certain  cases  there  may  be  an  almost  constant 
oozing  of  blood  from  the  shaggy  surface  of  degener- 
ated papillomata,  and  the  urine  may  be  almost  entirely 
blood,  altered  by  decomposition.  This  may  clot  in 
large  masses  in  the  bladder,  giving  rise  to  acute  re- 
tention, with  very  severe  pain,  for  which  the  only 
possible  treatment  is  removal  of  the  masses  of  ne- 
crotic tumour  and  blood  clot  piecemeal,  through  a 
perinseal  opening — usually  a  Cock's  puncture — and 
afterwards  washing  out  the  bladder  with  very  hot 
water  and  inserting  large  drainage  tubes.  It  is  quite 
impossible  to  wash  out  the  bladder  in  this  condition 
through  any  catheter  passed  by  the  urethra.  Masses 
of  degenerated  tissue  and  thick  dark  clotted  blood 
have  to  be  evacuated  and  free  drainage  must  be  pro- 
vided to  give  any  hope  of  relief.     Retention  of  urine 


48  BILHABZIOSIS. 

may  also  occur  from  the  blocking  of  the  urethral 
orifice  by  papillomata,  phosphatic  concretions,  stone, 
granular  debris  and  the  like. 

The  last  stage  in  an  advanced  bilharziosis  of 
the  bladder  is  somewhat  as  follows :  The  patient  is 
usually  a  man,  though  a  few  very  severe  cases  are 
met  with  in  women,  and  he  is  very  weak  and  anaemic, 
thin  and  haggard,  and  absolutely  miserable.  He  has 
constant  micturition  and  dribbling,  with  pain  in  the 
penis  and  deep  down  in  the  peringeum  near  the  rectum. 
He  very  often  carries  his  scrotum  in  his  hand  in  an 
attempt  to  relieve  the  pain.  The  history  is  usually 
absolutely  untrustworthy,  the  native  mind  having  no 
idea  of  the  duration  of  time.  On  examining  the  penis, 
the  meatus  will  be  wet  and  there  is  a  constant  slight 
dribbling  going  on.  On  passing  water  a  very  small 
quantity  is  voided  and  there  is  much  pain,  especially 
at  the  completion  of  the  act,  followed  by  a  slight  tem- 
porary relief.  The  urine  varies  in  appearance,  but  is 
usually  very  offensive,  dark-red  and  turbid,  and,  on 
standing,  deposits  phosphates,  debris,  blood,  and  ova. 
On  examining  the  abdomen  a  hard  mass  may  be  felt 
in  the  suprapubic  region.  This  lump  is  usually  not 
in  the  least  tender,  is  very  irregular  and  stony,  and 
may  extend  upwards  as  far  as  the  umbilicus  and  to 
any  extent  laterally.  One  or  both  kidneys  will  be 
found  enlarged  and  tender,  and  the  ureters  may  be 
felt  much  dilated  through  the  unusually  thin  ab- 
dominal wall.  The  whole  course  of  the  urethra  may 
be  hardened  or,  on  the  other  hand,  it  may  be  quite 


BILEARZIOSIS  OF  TEE    URINARY  SYSTEM.  49 

unaffected.  On  rectal  examination  the  bladder  will 
be  felt  firm  and  contracted,  or  simply  as  a  thick  hard 
mass;  and  bimanually,  with  the  other  hand  on  the 
abdomen,  the  great  thickening  of  and  around  the 
bladder  will  be  well  appreciated.  On  introducing 
the  sound,  it  can  often  just  be  passed  beyond  the 
neck  of  the  bladder,  and  then  only  with  severe  pain, 
into  a  very  much  contracted  cavity.  Masses  of  bil- 
harzial  tissue  may  be  felt,  crusted  with  concretions, 
but,  in  many  cases,  such  is  the  contraction  of  the 
space  within  the  bladder  that  beyond  feeling  that  the 
end  of  the  sound  is  free  within  a  small  cavity,  very 
little  else  can  be  made  out. 

The  usual  treatment  and  fate  of  these  advanced 
cases  is  that  a  perinseal  opening  into  the  bladder  is 
made  to  relieve  the  incessant  pain.  The  incision, 
passing  through  a  very  hard  mass,  opens,  at  what 
seems  to  be  a  great  distance  from  the  skin  surface, 
into  a  very  small  cavity,  which  is  at  first  difficult  to 
recognise  as  that  of  the  bladder.  On  introducing  the 
finger  and  dilating  up  the  wound  great  masses  of 
degenerated  tissue  are  found,  coated  with  phosphates, 
and  almost  completely  filling  what  remains  of  the 
bladder  cavity.  Large  pieces  of  concretions  or  struc- 
tureless "pinkish  cream-cheese"  come  away.  The 
bladder  walls,  when  they  can  be  made  out  at  all,  are 
greatly  thickened  and  all  the  surroundings  are  much 
indurated.  A  lot  of  decomposing  blood  clot  may  also 
be  evacuated,  mixed  with  very  offensive  urine.  If 
there  is  room  a  drainage  tube  is  introduced  into  the 


50  BILHARZIOSIS. 

bladder  and  stitched  to  the  edges  of  the  wound  (which 
is  itself  closed  by  suture),  and  the  urine  drained  into  a 
vessel  at  the  side  of  the  bed  by  syphon  action.  The 
patient  has  great  relief  for  two  or  three  days  after 
operation;  then  he  starts  a  diarrhoea,  which  nothing 
will  stop,  and  one  can  see  him  visibly  melting  away. 
His  temperature  goes  up  and  stays  up  and  becomes 
typically  septic.  His  anaemia  and  weakness  are 
extreme,  and  in  about  a  fortnight  he  dies  from  sheer 
exhaustion,  with  great  emaciation  and  the  severest 
possible  symptoms  of  septic  kidneys,  or  with  uraemia. 
The  condition  is  really  quite  hopeless  from  the  first ; 
but,  for  a  day  or  two  after  operation,  so  great  is  the 
relief  afforded  that  the  unwary  surgeon  is  inclined  to 
congratulate  himself  on  his  opportune  interference. 

Treatment  of  bilharziosis  of  the  bladder. — 
Our  first  duty,  in  connection  with  the  treatment  of 
this  awful  disease,  is  candidly  to  admit  that  there  is 
nothing  yet  known  that  has  any  effect  whatever  upon 
the  actual  cause  of  the  trouble,  the  bilharzia  worm 
itself.  And,  taking  into  consideration  the  early 
pathology  and  habitat  of  the  worm,  it  is  difficult  to 
see  how  we  can  expect  to  kill  the  invader  in  the  blood 
without  doing  fatal  damage  to  the  whole  organism  at 
the  same  time.  There  is  this  to  be  said,  however, 
that  there  are  certainly  many  instances  of  spontan- 
eous cure  of  the  disease,  hematuria  and  the  bladder 
irritability  lasting  for  a  varying  period  and  then  dis- 
appearing, never  to  recur.  This  fortunate  ending 
can  only  be  expected  to  happen  if  the  patient  is  re- 


BILHARZIOSIS   OF  THE    URINARY  SYSTEM.  51 

moved  from  the  possibility  of  re-infection ;  and  can 
never  occur  among  the  ordinary  rank  and  file  of  the 
sufferers  from  this  disease,  namely  the  agricultural 
labourers  of  Egypt.  Even  though  a  patient  exiles 
himself  entirely  from  Egypt,  cases  are  reported  in 
which  ova  have  continued  to  be  passed  in  the  urine 
for  several  years  afterwards.  What  it  is  that  leads  to 
the  death  of  the  worm  within  the  body  we  do  not 
know ;  but  it  is  comforting,  to  some  extent,  to  realise 
that  this  happy  result  does  sometimes  occur,  though, 
even  after  the  death  of  the  worms,  symptoms  may 
persist  for  a  long  time,  until  all  the  ova  are  eliminated 
from  the  body  in  the  urine  or  faeces  or  encapsuled. 

In  the  earliest  clinical  stages  of  the  disease,  when 
some  slight  irritability  and  painless  and  temporary 
hematuria  are  present,  very  good  results  frequently 
follow  the  administration  of  the  liquid  extract  of  male 
fern,  given  regularly  in  fifteen  minim  (1.0)  doses, 
three  times  a  day,  in  capsule.  A  long  course  of  male 
fern  and  washing  out  the  bladder  with  increasingly 
strong  solutions  of  nitrate  of  silver,  starting  with 
a  1  in  10,000  solution,  or  with  a  four  per  cent, 
solution  of  quinine,  has  sometimes  a  good  effect 
in  checking  the  hematuria  and  relieving  the  irri- 
tation. Boracic  acid  in  five  grain  (0.30)  cachets 
three  times  a  day,  or  irrigations  of  the  bladder  with 
adrenalin  in  normal  saline  solution,  may  also  prove 
of  service. 

One  also  gives  full  directions  as  to  diet,  but 
it  must  be  admitted  that,   even  if  such  are  carried 


52  BILHARZIOSIS. 

out,  very  little  benefit  is  likely  to  result.  As  the 
disease  progresses  and  cystitis  sets  in  (in  hospital 
practice  one  rarely  sees  a  case  before  this  has  hap- 
pened), considerable,  if  only  temporary,  benefit  may 
result  from  strict  anti-cystitic  treatment.  The  diet 
consists  of  milk  and  milky  foods  generally,  vegetable 
soups  and  farinaceous  food  of  all  kinds,  meat  being 
avoided.  The  best  diluent  and  cleanser  is  plain 
water,  which  may  be  given  in  large  quantity.  Bar- 
ley water  and  Vichy  water  (Source  Celestins)  are  also 
largely  used  and,  medicinally,  the  changes  must  be 
rung  on  salol,  urotropine,  benzoic  acid  and  the  ben- 
zoates  and  boracic  acid,  in  appropriate  doses.  Better 
than  any  of  these,  however,  is  the  time-honoured 
buchu  and  hyoscyamus  mixture,  usually  made  up 
with  bicarbonate  or  acetate  of  potassium,  fifteen 
grains  (1.0) ;  tincture  of  hyoscyamus,  half-a-drachm 
or  more  (2.5) ;  glycerine  or  syrup  of  orange,  half-a- 
drachm  (2.5)  ;  and  infusion  of  buchu  to  the  fluid 
ounce  (25.0).  This  mixture  is  given  four  times  a  day 
for  an  extended  period. 

Except  to  give  a  certain  amount  of  relief,  by 
clearing  the  bladder  of  accumulated  debris  and  de- 
composing urine,  washing-out  the  bladder  accom- 
plishes little ;  and,  even  in  the  earliest  stages,  it 
cannot  be  looked  upon  as  exerting  any  local  curative 
or  inhibitory  effect  on  the  disease.  For  this  mechan- 
ical washing  out  of  the  viscus,  plain  sterilised  water, 
or  boracic  or  quinine  solution,  may  be  used. 

From    this    stage    onwards,    treatment    must    be 


BILHARZIOSIS   OF   THE   URINARY  SYSTEM.  53 

entirely  symptomatic ;  and,  later,  the  question  of  the 
advisability  of  drainage  of  the  bladder  has  to  be 
considered.  In  general,  it  may  be  said  that  in  all 
cases  the  drainage  opening,  if  any,  must  be  made  in 
the  perinseum  and  not  in  the  suprapubic  region ;  and, 
further,  before  it  is  decided  upon  at  all,  a  careful 
examination  must  be  made  for  stone,  which,  in  spite 
of  the  already  awful  condition  of  the  bladder,  may 
and  does  give  rise  to  a  great  aggravation  of  the 
symptoms.  After  the  removal  of  the  stone,  immense 
relief  usually  follows  and  the  patient  considers  he  is 
cured  of  all  the  symptoms  worth  worrying  about. 
Drainage  must  be  undertaken  when  the  urine  is  very 
foul  and  there  is  evidence  of  early  septic  absorption, 
the  operation  being  either  a  Cock's  puncture  or  a 
median  perinseal  cystotomy,  followed  by  prolonged 
washing-out  of  the  bladder  and  the  introduction  of  a 
drainage  tube,  through  which  the  washing  may  be 
continued  for  some  time,  until  the  urgency  of  the 
symptoms  disappears,  after  which  the  wound  is 
allowed  slowly  to  close  of  itself.  Sometimes  a  fistula 
is  left  which,  though  acting  to  some  extent  as  a 
safety  valve,  distinctly  adds  to  the  patient's  discom- 
fort. Drainage  is  imperatively  called  for  in  all  cases 
of  acute  retention,  either  from  blocking  of  the  urethral 
orifice  by  stone,  concretion,  growth  or  debris,  or  from 
clotted  blood,  as  already  described.  The  presence  of 
a  drainage  opening  adds  a  very  considerable  risk  in 
all  these  cases,  as  septic  infection  very  readily  sets 
in   in  such  a  filthy   bladder   and   goes  very  rapidly 


54  BILHARZIOSIS. 

upwards  to  the  kidneys.  In  cases  of  haemorrhage  the 
injection  of  very  hot  water  or  adrenalin  solutions 
may  be  of  temporary  service. 

All  stones  should  be  treated,  as  far  as  possible,  by 
lithotrity  ;  and,  in  spite  of  the  extensive  changes  in 
the  bladder,  the  results  of  this  operation,  qua  opera- 
tion and  as  a  reliever  of  symptoms,  are  remarkably 
good.  It  might  almost  be  stated  as  a  golden  rule 
that  no  stone  in  a  bilharzial  bladder  should  ever  be 
treated  by  a  cutting  operation,  unless  the  condition 
of  the  bladder  is  such  as  to  call  for  drainage,  or 
the  pain  is  so  severe  and  constant  as  to  require 
the  bladder  to  be  put  at  rest,  by  providing  a  free 
artificial  outlet  for  the  urine.  Further,  if  a  cutting 
operation  is  done,  it  must  be  in  the  perinseum  and 
not  in  the  suprapubic  region.  It  seems  almost  as  if 
the  further  you  keep  away  from  the  kidneys  with 
the  knife  the  better  the  immediate  result  and  the 
prognosis  for  the  future. 

It  must  always  be  remembered  that  the  true  cause 
of  death  even  from  a  very  early  stage  in  the  proceed- 
ings, lies  in  the  ureters  and  kidneys ;  moreover  a  fatal 
result  in  cases  of  stone  after  a  cutting  operation  and, 
for  that  matter,  after  lithotrities,  rare  as  they  are,  is 
almost  always  to  be  ascribed  to  the  condition  of  the 
kidneys  and  ureters  and  the  septic  complications 
already  present  there  at  the  time  of  the  operation. 

Some  temporary  relief  may  be  obtained  in  severe 
cases  by  such  palliative  measures  as  hot  fomentations 
to  the  abdomen,  morphia  and  belladonna  suppositories, 


BILHARZIOSIS   OF  THE   URINARY  SYSTEM.  55 

hot  baths,  passing  urine  with  the  penis  immersed  in  a 
cup  of  hot  water,  etc.,  but  all  of  these  are  only  con- 
fessions of  failure  to  cope  with  the  disease  in  anything 
like  a  satisfactory  manner. 

For  cancer  associated  with  bilharziosis,  and  the 
fibrous  indurations  in  and  surrounding  the  bladder, 
nothing  can  be  done;  though  some  relief  may  be 
afforded  by  hypodermic  injections  of  morphine  for  the 
pain,  and  a  temporary  respite  from  the  awful  irrita- 
tion and  constant  micturition  may  be  obtained  by 
perineal  drainage.  These  measures  are  unfortunately 
only  adopted  in  our  endeavour  to  give  the  patient 
a  more  comfortable  death. 

Bilharziosis  of  the  urethra.— The  male  urethra 
is  very  frequently  the  seat  of  bilharziosis,  and  is  far 
more  often  affected  than  the  female  urethra.  When 
the  disease  does  occur  in  the  female  it  is  usually  part 
of  a  general  involvement  of  the  bladder,  instead  of 
being  a  separate  local  manifestation,  as  is  the  case 
in  the  male  canal. 

Occasionally  small  elevations,  resembling  a  urethral 
caruncle,  but  containing  bilharzia  ova,  are  met  with  at 
the  orifice  of  the  female  urethra  ;  and,  quite  recently, 
a  case  came  for  operation  in  which  there  was  a  papil- 
lomatous mass — with  much  general  infiltration  of  the 
mucous  membrane — which  was  attached  by  a  loose 
pedicle  to  the  base  of  the  bladder  and  had  protruded 
from  the  urethral  orifice  of  a  small  girl,  forming  a  mass 
the  size  of  a  large  walnut.  The  tumour  had  all  the 
typical  bilharzial  characters. 


56  BILHABZIOSIS. 

Symptoms. — The  symptoms  of  early  bilharziosis 
of  the  male  urethra  are  usually  localised  pain  in  the 
perinseum  and  a  hard,  tender  lump  at  the  seat  of  the 
pain.  There  is  a  certain  amount  of  difficulty  in  pass- 
ing urine,  and  this  symptom  may  be  so  marked 
that  many  cases  are  sent  into  hospital  as  impacted 
stone  in  the  urethra.  On  careful  examination  with 
the  sound  it  will  be  found  that,  though  there  is  often 
some  little  difficulty  in  passing  the  instrument  beyond 
the  lump  in  the  perinaeum,  it  goes  fairly  easily,  with  a 
little  coaxing,  into  the  bladder ;  and,  except  for  some 
roughness  at  the  thickening,  no  stone  is  to  be  felt. 
The  point  of  the  sound  may  catch  in  the  wall  of  a 
small  thick- walled  cavity  in  passing,  and  the  grating 
thus  produced  may  be  easily  mistaken  for  the  rubbing 
against  a  stone  impacted  in  this  situation.  As  the 
disease  advances  the  lump  becomes  larger  and  softer 
and  approaches  the  skin  surface  in  the  posterior  part 
of  the  scrotum,  or  just  behind  it,  with  all  the  symptoms 
of  a  subacute  periurethral  abscess.  Eventually  this 
leads  to  a  thinning  of  the  skin  and  a  discharge  of  thick 
offensive  pus  and  granular  debris,  and,  very  soon,  a 
slight  leakage  of  urine  from  the  opening  during  the 
act  of  micturition.  In  this  way  a  urinary  fistula  is 
produced  and  will  persist  indefinitely  unless  radical 
treatment  is  adopted.  On  cutting  down  in  such  a  case 
one  opens  into  a  thick- walled  cavity,  which  has  a  small 
connection  with  the  urethra  and  is  filled  with  pus, 
granular  debris,  and  a  few  drops  of  urine.  The  granular 
tissue  will  contain  ova  ;  the  walls  of  the  urethra  above 


Fig.  14. — Bilharziosis  of  the  penis  and  scrotum  in  a  young  boy.  The  glans 
penis  and  the  prepuce,  indeed  the  whole  penis  is  in  a  condition 
of  false  elephantiasis,  and  riddled  with  sinuses,  as  is  also  the 
scrotum.  The  sinuses  are  really  fistulas  in  connection  with  extensive 
bilharziosis  of  the  urethra.  Old  bilharzial  sinuses  are  also  seen  in 
the  left  iliac  region. 

(Photograph  of  a  case  in  the  Author's  wards  in  Easr-el-Avny  Hospital,  Cairo.) 


BILHARZIOSIS   OF  THE   URINARY  SYSTEM.  57 

and  below  the  fistula  will  be  thickened  and  its  mucous 
membrane  softened  and  infiltrated  with  bilharzial 
granulation  tissue. 

Treatment. — The  treatment  of  such  a  case  con- 
sists  in   the  complete  removal  of  all  the   infiltrated 
tissue  right  up  to  the  level  of  the  urethra,  while  the 
urethral    edges  of  the   fistula   must   be  well   scraped 
with  a  sharp  spoon  and  all  the  granular  tissue  removed. 
If  there  is  any  stricture  of  urethra  an  external  ureth- 
rotomy must  be  performed  also.     The  wound  is  care- 
fully plugged  with  gauze  and  allowed  to  granulate  up 
from  the  bottom,  a  full- sized  catheter  being  passed  at 
short  intervals  while  the  healing  process  is  going  on. 
In  the  majority  of    cases  a  fistula    has    already 
formed  before  any  treatment  is  sought,  and  these  cases 
present    every    degree    of    severity,  from    a    single 
perinaeal  fistula,  usually  to  one  side  of  the  middle  line, 
just  behind  the  scrotum,  with  little,  if  any,  surround- 
ing inflammation,  to  the  formation  of  a  hard  indurated 
tissue,  occupying  the  whole  perineum  and  surround- 
ings and  riddled  with  fistulous  openings   in   various 
directions.     The  skin  of  the  scrotum  is  often  hardened 
and  swollen  with  firm  oedema,  and  the  fistulous  track 
can  be  felt  coming   up   from    the  urethra,  as  a  firm 
column    of  almost   stony  hardness.       The  urethra  is 
also  thickened  and  hard  and  may  be  much  narrowed 
in  its  anterior  part  and  the  meatus  much  contracted. 
The  fistula  discharges  pus,  granular  debris  and  urine, 
and  there  may  be  considerable  eczema    around   the 
opening.     There  may  also  be  a  thin  purulent  discharge 


58  BILHARZIOSIS. 

from  the  meatus,  which  may  easily  be  mistaken  for 
that  of  chronic  gonorrhoea.  On  passing  a  sound  it 
usually  enters  the  bladder  easily,  though  in  some 
cases,  owing  to  the  destruction  of  a  portion  of  the 
urethra  by  the  disease,  an  absolutely  impermeable 
stricture  may  be  present.  The  fistulous  track  runs  in 
the  substance  of  a  very  hard  fibrous  tissue  which  is 
directly  continuous  with  a  much  thickened  urethra, 
the  bilharzial  change  in  which  extends  for  any  length 
along  it.  The  fibrous  sheath  is  lined  internally  with 
soft  bilharzial  tissue,  which  extends  up  to  the  base 
of  the  ulceration  forming  the  urethral  end  of  the 
fistula.  Ova  are  to  be  found  in  this  soft  tissue,  and 
sometimes  worms  may  be  seen  in  open  spaces 
beside  the  fibrous  sheath  of  the  fistulse  and  in  the 
periurethral  tissue. 

From  the  preceding,  comparatively  mild,  cases  all 
grades  of  severity  are  met  with.  The  penis,  the 
scrotum,  the  skin,  and  soft  parts  of  the  perinseum  and 
the  buttocks,  and  even  the  suprapubic  region,  may 
all  be  individually  or  collectively  riddled  with  fistulse, 
having  the  characters  just  described,  the  intervening 
soft  parts  being  transformed  into  masses  of  scar  tissue. 
The  fistulse  branch  in  all  directions,  each  separate 
branch  often  opening  at  a  considerable  distance  from 
the  original,  "  but  it  will  be  noticed  that  all  the  fistulse 
arise  from  a  very  short  length  of  the  urethra,  namely, 
that  portion  between  the  posterior  margin  of  the 
scrotum  and  the  bulb."  (Milton.)  It  is  not  so 
common  to  find  fistulse  arising  from  the  penile  urethra, 


Fig.  15.— Bilharziosis  of  the  penis  in  a  boy  of  nine.  The  false  elephanti- 
asis of  the  glans,  prepuce,  and  skin  of  the  penis  generally  is 
well  seen,  but  there  are  no  sinuses  or  bilhax-ziosis  of  the  urethra 
in  this  case.  (It  may  sometimes  be  difficult  to  diagnose  this  con- 
dition from  filarial  elephantiasis,  but  the  comparative  freedom  of 
the  glans  in  filarial  invasion  is  an  important  feature.) 

(Photograph  of  a  case  under  the  care  of  Mr.  0.  IV.  Richards  in  Easr-rt-Ainy 
Hospital,  Cairo.) 


BILHARZIOSIS   OF  THE    URINARY  SYSTEM.  59 

but,  when  they  do  so,  there  is  usually  considerable 
destruction  of  the  urethra  in  its  anterior  part,  and 
the  prepuce,  skin  of  the  penis,  and  the  organ  generally 
often  becomes  transformed  into  a  mass  of  false  ele- 
phantiasis, a  condition  which  is  also  seen  in  the 
scrotum  in  the  case  of  fistulae  traversing  this  struc- 
ture.    (Figs.  14  and   15.) 

In  some  instances  the  glans  penis  is  much  infil- 
trated and  may  be  extensively  destroyed  by  ulcer- 
ation, and,  although  the  urethra  is  also  affected,  it 
seems  that  the  deposit  originated  in  the  tissues  of  the 
glans  itself. 

No  hope  of  cure  can  be  expected  in  bilharzial 
urethral  fistulae  unless  the  whole  affected  tissue 
is  removed.  Very  extensive  operations  are  often 
necessary  to  effect  this,  and  half -measures  are  useless. 
The  fistulae  must  be  followed  up  in  their  whole  length 
and  they  and  their  surrounding  fibrous  tissue,  how- 
ever extensive  it  may  be,  freely  excised.  Large  por- 
tions of  the  scrotum  may  require  removal,  as  well  as 
portions  of  the  skin  and  subcutaneous  tissues  of  the 
perinaeal,  gluteal,  ischio-rectal  and  suprapubic  regions. 
To  dissect  out  certain  tracts  the  scrotum  may  require 
to  be  split  in  half.  The  testicles  are  almost  never 
affected,  though  fistulous  tracks  burrow  in  all  direc- 
tions in  the  scrotal  tissues.  If  penile  fistulas  are 
present  they  must  be  just  as  radically  excised,  and, 
in  all  cases,  after  the  urethra  itself  has  been  freely 
scraped,  the  wounds  must  be  made  as  clean  as  pos- 
sible and  tightly  plugged  with  gauze,  to  allow  them 


60  BILEARZIOSIS. 

to  granulate  up  from  the  bottom  and  from  the  level 
of  the  urethra. 

The  treatment  of  the  urethra  varies  with  the  con- 
dition. In  some  cases  the  mass  of  fibrous  tissue 
seems  to  be  closely  incorporated  with  the  urethral 
walls  and  an  external  urethrotomy  must  be  done 
through  this  mass  into  the  urethra  and  any  stricture 
freely  divided  in  the  incision.  In  other  cases  the 
fistula  can  be  traced  in  between  the  corpus  spongiosum 
and  the  corpora  cavernosa  to  the  side  of  the  urethra, 
where  it  opens  laterally  or  even  in  the  roof.  This 
mass  of  tissue  must  be  removed  right  up  to  the  canal 
and  the  ragged  opening  into  the  urethra  well  scraped 
with  a  spoon  and  all  the  soft  bilharzial  tissue  removed. 
Three  or  four  days  after  the  operation  a  full-sized 
catheter  is  passed  and  then  every  few  days  until  heal- 
ing is  complete.  The  large  open  wounds  often  take 
a  considerable  time  to  heal,  but  with  careful  packing 
and  proper  attention  the  result  of  these  cases  is  usually 
very  satisfactory,  though  repeated  operations  are  often 
necessary.  Sometimes  an  operation,  similar  to  that 
for  the  complete  removal  of  an  elephantiasis  of  the 
scrotum,  has  to  be  performed ;  and  in  this  case  it  is 
often  advisable  to  place  a  drainage  tube  in  the  bladder 
through  the  urethral  incision  for  some  days  to  prevent 
any  infiltration  of  the  new  scrotal  wound  with  urine. 
When  the  urethra  is  very  much  destroyed,  and  there 
is  difficulty  in  finding  any  track  at  all,  once  the  remains 
of  the  canal  have  been  found  a  large  catheter  must 
be  tied  in  the  bladder  for  a  few  days. 


BILEARZ10SIS   OF  TEE   URINARY  SYSTEM.  61 

In  nearly  all  cases  of  bilharziosis  of  the  urethra 
the  bladder  is  affected  with  the  disease,  and  the  ulti- 
mate j3rognosis  of  the  case  must  depend  upon  the 
bladder,  ureter  and  kidney  condition  rather  than  upon 
that  of  the  urethra. 

In  his  "  Three  Lectures  on  Bilharzia,"  Milton 
divides  these  urinary  fistulas  into  roof  and  floor  fistulas 
as  follows  :  ' '  By  far  the  greater  number  of  these  fistulas 
take  their  origin  from  the  roof,  or  pubic  side,  of  the 
urethra ;  those  coming  from  the  floor,  or  perinasal 
side,  being  quite  the  exception.  The  floor  fistulas, 
though  usually  found  in  the  urethra  just  in  front  of 
the  bulb,  are  not  so  strictly  confined  to  this  part  as 
the  roof  fistulas  and  are  fairly  frequent  in  the  penile 
urethra.  It  is  very  rare  to  find  the  corpora  cavernosa 
infiltrated  with  bilharzial  tissue,  all  fistulous  tracks 
running  in  the  corpus  spongiosum,  or  between  it  and 
the  adjacent  corpus  cavernosum.  The  roof  fistulas 
are  probably  formed  originally  by  the  destruction  of 
a  portion  of  the  urethral  wall  by  bilharzial  deposit, 
which  extends  into  the  substance  of  the  corpus  spongi- 
osum and  then  into  the  space  between  this  structure 
and  the  corpus  cavernosum  on  one  side  or  the  other. 
It  is  thus  directed  towards  the  perinasum,  where  it 
eventually  arrives  at  the  skin  and  opens  externally,  to 
one  side  of  the  middle  line,  and  the  fistula  is  complete. 

"  The  amount  of  inflammation  involved  in  the  for- 
mation of  a  roof  fistula  is  very  small,  in  marked  contrast 
to  that  occurring  with  floor  fistulas.  In  the  latter 
variety  the  destruction  of  tissue  occurs  on  the  perinasal 


62  BILHARZIOSIS. 

side  of  the  urethra  with  the  formation  of  an  nicer, 
which,  being  in  a  dependent  position,  acts  as  a  trap, 
catching  and  retaining  the  decomposing  matter  from  the 
bladder.  A  septic  inflammation  is  set  up  in  this  ulcer 
trap  and  a  periurethral  abscess  formed,  with  gradually 
increasing  surrounding  fibrous  induration,  owing  to  the 
constant  irritation.  This  fibrous  tissue  becomes  firmer 
and  firmer,  until  it  is  almost  of  stony  hardness,  and 
gradually  approaches  the  surface  of  the  perinseum,  bear- 
ing in  its  centre  a  gradually  elongated  pouch,  constantly 
filled  with  pus,  urine  and  decomposing  matter.  The 
urethra  in  front  of  the  ulcer  becomes  thickened  by  irri- 
tation of  the  discharges  of  the  filthy  cavity  into  its 
lumen.  The  result  is  that  the  whole  urethra,  from  the 
site  of  the  fistula  even  to  the  meatus,  is  narrowed  and, 
not  uncommonly,  there  may  be  complete  obliteration  of 
the  canal  by  cicatricial  tissue,  due  to  the  final  healing 
of  long-continued  ulceration  of  the  urethra,  set  up  and 
maintained  by  the  discharge  from  the  fistula  abscess. 
In  roof  fistula  there  is  no  obstruction  of  the  urethra 
at  all." 

The  pathological  conditions  met  with  in  the 
urethra  are  mainly  those  of  general  infiltration  of 
the  mucous  membrane  and  ulceration.  Not  unfre- 
quently  small  raised  grape- like  projections  may  occur 
on  the  mucous  surface,  but  there  is  an  absence  of  any 
extensive  papillomatous  change. 

Reference  will  be  made  later  to  other  forms  of 
fistulas,  due  to  bilharziosis,  in  the  region  of  the  per- 
inaBum,  which  sometimes  secondarily  acquire  a  com- 


BILHARZIOSIS   OF  THE    URINARY  SYSTEM.  63 

munication  with  the  urethra ;  and  there  are  certain 
other  cases,  in  which  there  is  a  deposit  of  bilharzial 
tissue  in  the  form  of  a  hard  lump  in  the  corpus  spon- 
giosum, or  even  in  the  corpora  cavernosa,  which  can 
sometimes  be  completely  removed  by  operation  and 
which  is  then  seen  to  have  no  connection  with  the 
urethral  canal.  Sometimes,  again,  an  external  sinus 
leads  down  to  a  hard  mass  of  similar  characters,  but 
without  any  urethral  communication.  The  structure 
of  these  masses  is  typical  bilharzial  tissue,  and  they 
are  due  to  the  presence  of  a  pair  or  a  small  colony 
of  worms  and  their  ova  in  the  venous  spaces  of  the 
erectile  tissue ;  and,  though  it  is  probable  that  they  will 
eventually  open  into  the  urethra,  at  this  stage  the 
mucous  membrane  of  the  canal  is  entirely  unaffected. 


IV. 

BILHARZIOSIS  OF  THE  INTESTINAL  TRACT. 

As  might  be  expected,  from  the  extensive  distribution 
of  the  bilharzia  worm  and  its  ova  in  the  portal  circula- 
tion, the  intestines  may  be  severely  affected ;  and,  next 
to  the  bladder  and  urethra,  the  lower  part  of  the  in- 
testinal tract,  especially  the  rectum,  is  the  most  fre- 
quent seat  of  the  disease. 

Ova  have  been  found  in  the  muscular  wall  of  the 
stomach,  the  condition  being  later  verified  post-mortem 
(Goebel),  but  not  in  the  mucous  membrane,  and 
bilharzial  manifestations  may  be  found  in  any  part  of 
the  mucous  membrane  of  the  intestinal  tract,  from  the 
ileum  to  the  anus. 

Three  main  sets  of  lesions  may  occur  in  the  intes- 
tines. The  first  consists  in  the  formation  of  much  re- 
dundant mucous  membrane,  due  to  its  general  infiltra- 
tion, and  of  papillomatous  and  sessile  masses.  In  the 
second  of  the  series,  ulceration  is  the  most  prominent 
feature ;  while  in  the  third  the  most  striking  change  is 
a  very  marked  induration  and  thickening  of  the  con- 
nective tissue  between  the  layers  of  the  peritoneal 
attachments  of  the  gut. 

In  every  part  of  the  tract  liable  to  infection,  the 
only  part  apparently  free  being  the  stomach  and  duo- 

64 


BILHARZIOSIS   OF  THE  INTESTINAL  TRACT.  65 

denuin,  papillomata,  usually  definitely  pedunculated, 
and  of  varying  sizes  and  shapes,  are  the  most  common 
manifestations.  In  some  cases  they  are  but  sparsely 
scattered  over  the  surface  of  a  vascular  infiltrated 
mucous  membrane,  but  in  others  very  thickly  studded 
throughout  it ;  and  towards  the  lower  part  of  the  sig- 
moid flexure  and  in  the  rectum  large  pendulous  masses, 
dragging  with  them  a  good  deal  of  lax  mucous  mem- 
brane, occur  and  may  be  extruded  from  the  anus  on 
slight  straining. 

The  papillomata  in  the  intestine  present  no  special 
local  characteristics,  but  in  some  situations,  particu- 
larly in  the  descending  colon,  they  are  extremely  liable 
to  slough  off  at  their  base.     A  dark  ring  of  necrosis  is 
seen  round  the  pedicle,  which  gradually  deepens  until 
separation  takes  place  at  this  line,  leaving  a  raw  sur- 
face, which  remains  as  an  ulcer  with  rather  ragged 
edges  and  an  excavated  base.     There  may  be  consider- 
able general  thickening  of  the  coats  of  the  bowel  in  the 
neighbourhood  of  these  ulcers,  but  there  is  no  local  in- 
duration at  their  base.     In  some  specimens  all  stages 
in  the  separation  of  the  papilloma  and  the  formation 
of  an  ulcer  may  be  seen.     When  a  large  area  of  the 
mucous  membrane  of  the  gut  is  studded  with  ulcers  of 
this  nature,  both  from  its  appearance  and  the  symptoms 
it  produces,  it  well  merits  the  name  of  "  bilharzial 
dysentery  "  which  has  been  given  to  it.     (See  Fig.  10.) 
Another  pathological  change  consists  in  a  great 
thickening  of  all  the  coats  of  the  gut  with  extensive 
dense  fibrous  tissue  formation  between  the  layers  of 


66  BILRABZIOSIS. 

the  peritoneal  attachments.     This  condition  is  most 
commonly  seen  in  the  meso-C8ecum,  transverse  meso- 
colon, meso-sigmoid  and  the  meso-rectum,  but  it  is  not 
confined  to  these  situations.     Within  the  thickened  gut, 
the  calibre  of  which  is  much  diminished  by  papillomata 
and  sessile  masses,  a  lot  of  thick  mucus  is  present ;  and 
it  is  difficult  to  see  how  the  f seces  can  pass  the  affected 
section,  and  yet  one  has  never  seen  a  case  of  intestinal 
obstruction  due  to  this  bilharzial  change.     It  may  be 
that  the  mucus  acts  as  a  lubricant  and  so  allows  masses 
of  faeces  to  slip  past  the  narrowed  portions  of  the  gut. 
The  clinical   aspects   of   this   condition  are  very 
well  exhibited  by  the  case   of   a    young  man  who 
gave  an  indefinite  history  of  colicky  pains  in  the  abdo- 
men and   the  passage    of    blood  and  mucus    in   the 
motions  for   nearly  two  years.     Ova  were  found   in 
the  fseces   and    small    papillomatous  growths   in   the 
rectum.     Above  the  umbilicus,  in  the  middle  line  of 
the  abdomen,  was  a  curved  hard  tumour,  dull  on  per- 
cussion, freely  movable  and  somewhat  tender.     Both 
liver   and   spleen   were  enlarged.      On   opening  the 
abdomen  a  soft  nodule,  the  size  of  an  almond,  was  cut 
through  on  the  anterior  parietal  peritoneum,  and  simi- 
lar masses  were  found  in  the  omentum.     The  mesen- 
teric glands  were  enlarged,  but  were  much  firmer  in 
consistence  than  the  nodules.      The  transverse  colon 
was  found  to  contain  a  large  hard  tumour  within  its 
lumen ;    and,    on   making   an   incision   into  the  gut, 
a    fleshy    mass    with   a   smooth   undulating   surface, 
firmly  incorporated  with    the  wall    of   the    colon   at 


BILHARZIOSIS   OF  THE  INTESTINAL   TRACT.         67 

its  meso-colic  attachment  and  extending  for  some 
six  inches  or  more  along  it,  was  found.  In  this 
case  there  was  not  much  thickening  or  fixation  of  the 
meso- colon  ;  but  in  the  case  of  another  patient  with  a 
tumour,  in  the  same  situation,  the  induration  between 
the  layers  of  the  peritoneal  attachment  was  much 
more  marked.  Similar  conditions  have  been  found 
about  the  caecum  and  the  sigmoid,  and  in  these  situa- 
tions the  appendices  epiploicse,  in  addition  to  the 
peritoneal  folds,  were  the  seat  of  a  firm  bilharzial 
infiltration.  The  lumen  of  the  gut  was  filled  with 
innumerable  papillomata,  or  much  constricted  in  its 
calibre  by  elongated  sessile  masses,  and  externally 
masses  of  varying  size  and  firmness  were  scattered 
over  the  serous  surface.  The  appendix  may  be  found 
firmly  matted  to  the  caecum  and  its  surroundings,  or 
independently  the  seat  of  a  bilharzial  process.  The 
mesenteric  glands  in  the  neighbourhood  of  these 
massive  lesions  in  and  around  the  gut  are  swollen  and 
infiltrated,  and  there  is  generally  also  an  ulceration 
in  other  parts  of  the  tract,  the  main  symptoms  being 
those  of  dysentery,  the  presence  of  the  mass  and  of  ova 
in  the  fseces  and  other  symptoms  of  the  general  infec- 
tion confirming  the  bilharzial  nature  of  the  condition. 
(Fig.  16.) 

All  the  cases  of  this  nature  I  have  hitherto  diag- 
nosed have  been  treated  by  an  exploratory  laparotomy 
and  then  by  a  simple  enterotomy  over  the  site  of  the 
mass  in  the  bowel.  Through  this  opening  pieces  of 
papillomata  have  been    removed   and  the   diagnosis 


68  BILHABZIOSIS. 

thus  confirmed,  and  then  the  small  incision  has  been 
sutured  and  the  abdomen  closed.  In  every  case  the 
result  of  this  procedure  has  been  most  satisfactory ; 
the  dysenteric  symptoms  have  completely  disappeared 
and  the  tumours  appreciably  diminished  in  size.  Why 
they  should  do  so  one  cannot  imagine  but  the  fact 
deserves  to  be  mentioned,  as  when  one  remembers  the 
very  general  involvement  of  the  other  portions  of  the 
intestinal  tract  in  these  cases,  no  severe  operation, 
such  as  excision  of  the  affected  portion  of  the  gut, 
can  ever  be  justified. 

Many  of  the  changes  already  described  as  common 
to  mucous  membranes  in  general  are  well  seen  in  the 
intestine  and  especially  in  the  rectum;  "but  the 
changes  which  are  most  marked  and  most  fully  devel- 
oped are  those  which  make  for  an  increase  of  growth 
rather  than  the  changes  that  bring  about  necrosis; 
and  thus  the  disease  develops  on  different  lines  from 
those  followed  in  the  bladder,  where  necrosis  is  more 
marked.  Thus  the  hard  indurated  patches  common 
in  the  bladder  are  never  found  in  the  rectum ;  but, 
instead,  the  mucous  membrane  becomes  hypertrophied 
and  excessively  vascular,  the  surface  layers  are  deeply 
injected  and  readily  bleed  when  handled,  and  the 
appearance  of  the  surface  resembles  rich  red  velvet. 
After  a  time,  the  elements  of  the  mucous  membrane, 
probably  owing  in  part  to  their  excessive  nutrition, 
take  on  abnormal  growth,  with  thickening  of  the 
structure  and  general  increase  in  bulk,  and  with  ex- 
cessive local  overgrowth,   which  takes  the  form  of 


Fig. 


16.— Bilharziosis  of  the  sigmoid  flexure  and  meso-sigrnoid.  The 
processes  of  submucous  tissue  running  up  into  the  papillomata  are 
well  seen,  and  also  the  filling  of  the  lumen  of  the  gut  with  masses 
ot  bilharzial  growth,  and  the  great  thickening  of  all  the  coats  of 
the  bowel.  The  meso-sigmoid  is  enormously  thickened  and  infil- 
trated with  bilharzial  tissue,  in  which  many  coupled  worms  are 
to  be  found.    {See  Fig.  2.) 

(From  a  specimen,  prepared  by  Professor  Symmers,   in  the   Pathological 
Museum  of  the  Scliool  of  Medicine,  Cairo.) 


Fig.  17.— Two  enormous  masses  of  bilharzial  papillomata  protruded  from 
the  anus  of  a  boy  of  twelve.  They  were  removed  with  considerable 
temporary  relief. 

(Photograph  of  a  case  in  the  Authors  icards  in  Easr-el-Ainy  Hospital,  Cairo.) 


BILHABZIOSIS   OF  TEE  INTESTINAL   TRACT         69 

polypoid  adenomatous  tumours.  Near  the  anus  these 
polypoid  tumours  bear  some  resemblance  to  ordinary 
haemorrhoids,  but  within  the  gut,  and  especially  be- 
yond the  internal  sphincter,  they  differ  materially 
from  these  latter.  In  the  first  place,  in  a  given  area 
they  are  infinitely  more  numerous  than  piles  ever 
are ;  and,  instead  of  being  rounded  and  smooth  like 
haemorrhoids,  their  surface  is  velvety,  from  thicken- 
ing of  the  mucous  membrane  itself,  and  the  outline  is 
broken  up  in  all  directions  by  the  formation  of  secon- 
dary polypi,  growing  from  their  own  surface  and 
branching  in  all  directions,  until  the  larger  and  fully- 
developed  tumours  bear  a  great  resemblance  to  red 
branching  coral.  These  tumours  extend  high  up  in 
the  rectum  beyond  the  reach  of  the  finger,  and  this  is 
so  invariably  the  case  that  it  would  suggest  the  idea 
that  the  affection  of  the  rectum  begins  from  above, 
in  the  neighbourhood  of  the  sigmoid  flexure,  and  pro- 
ceeds downwards."  (Milton.)  As  in  other  parts  of 
the  intestinal  tract,  stricture  of  bilharzial  origin  is 
never  found  in  the  rectum. 

In  the  lower  part  of  the  rectum,  the  most  common 
seat  of  intestinal  bilharziosis,  the  symptoms  are  those 
of  tenesmus,  with  an  irritative  diarrhoea  and  the  passage 
of  thick  glairy  mucus  and  blood.  Very  often  mucus 
and  blood  are  passed  without  any  faecal  matter  at  all, 
and  the  straining  may  be  almost  continuous,  and 
the  tenesmus  very  severe,  especially  if  pendulous 
masses  are  protruded  from  the  anus  and  caught  by 
the  sphincter  during  defaecation.     This  also  increases 


70  BILHARZIOSIS. 

the  bleeding,  and  gives  rise  to  very  great  pain.  On 
examination  the  anus  is  usually  somewhat  patulous, 
and,  on  slight  straining,  a  polypoid  mass,  and  with 
it  a  good  deal  of  lax  swollen  mucous  membrane,  may 
be  protruded.  The  papillomata  have  the  usual  bil- 
harzial  characters,  and  bleed  readily  on  digital  exam- 
ination. A  large  number  of  polypi  of  various  sizes 
and  forms  may  be  felt  round  the  anus  and  as  far  up 
the  rectum  as  the  finger  can  reach.  On  removing  the 
finger  thick  pieces  of  mucus  are  discharged.  The 
microscopical  examination  of  this  mucus  and  blood 
reveals  the  presence  of  ova.     (Fig.  17.) 

At  a  later  stage  of  the  disease  there  may  be  a  com- 
plete prolapse  of  first  a  ring  of  thickened  and  swollen 
mucous  membrane,  perhaps  bearing  on  its  surface 
many  ranges  of  sessile  and  papillomatous  masses,  and, 
in  extreme  cases,  a  large  part  of  the  rectum  may  be 
almost  constantly  prolapsed. 

It  sometimes  happens  that  fistulse  form  in  con- 
nection with  bilharziosis  of  the  rectum.  They  cause 
considerable  destruction  of  the  parts  round  the  anus 
and  buttocks  or  may  even  extend  to  the  peringeurn. 
The  mode  of  their  formation  is  very  similar  to  that 
described  in  the  case  of  urethral  fistula?,  and  the  treat- 
ment must  follow  the  same  lines. 

Treatment, — The  treatment  of  bilharziosis  of  the 
intestinal  tract  resolves  itself  into  that  of  bilharzial 
dysentery  and  of  rectal  bilharziosis.  The  ' '  dysentery  " 
must  be  treated  with  all  the  various  drugs  and  the 
strict  regime  of  a  case  of  true  dysenteric  diarrhoea,  and  in 


JBILEABZIOSIS  OF  TEE  INTESTINAL   TRACT.         71 

some  cases  large  injections  of  astringent  lotions  may 
be  of  service.    Reference  has  already  been  made  to  the 
good  effect  of  an  exploratory  laparotomy  and  of  enter- 
otomy  when  the  dysentery  is  complicated  with  tumours 
of  bilharzial  origin.     The  treatment  of  bilkarziosis  of 
the   rectum  must  be  almost    entirely   palliative  and 
symptomatic.     The  severe  tenesmus  may  sometimes 
be  temporarily  relieved  by  stretching  the  sphincter  ani 
under  an  anaesthetic,  and,  at  the  same  time,  a  strong 
astringent  lotion — sulphate  or  chloride  of  zinc,  for  ex- 
ample— may  be  injected  into  the  rectum,  or  the  actual 
cautery  may  be  applied  in  longitudinal  lines  all  round 
the  lumen  of  the  gut.     Protruding  masses  must  be  cut 
off,  after  ligaturing  their  pedicles.     In  other  cases  a 
deep  ring  of  lax  and  prolapsed  mucous  membrane  may 
be  excised,  like  an  extensive  Whitehead's  operation,  or 
an  excision  of  a  portion  of  the  whole  thickness  of  the 
rectum  may  even  be  justifiable  and  be  attended  with 
very  good  results.     At  best,  however,  any  treatment 
gives  but  temporary  relief ;  the  dysenteric  symptoms 
persist  in  making  the  patient's  life  a  perfect  misery  to 
himself,  even  if  the  tenesmus  and  other  distressing 
symptoms  in  the  lower  portion  of  the  intestine  are 
relieved. 

Reference  has  already  been  made  to  the  occurrence 
of  bilharzial  deposits  in  the  peritoneum,  omentum  and 
mesenteric  glands,  and  ova  have  also  been  found  in 
the  pancreas.  Bilharzial  abscess  of  the  liver  also  occurs, 
and  Kartulis  and  Symmers  have  described  a  periportal 
cirrhosis    of   the   liver   with,    in  addition,    thickened 


72  BILHARZIOSIS. 

patches  of  bilharzial  fibrous  tissue  on  the  surface  of  the 
organ.  Similar  patches  have  been  demonstrated  on 
the  spleen,  but  so  far  no  cases  of  ova  in  the  sub- 
stance of  the  spleen  have  been  reported.  The  ova  have 
also  been  found  in  gall-stones  and  in  the  pancreas 
(Symmers) ;  and,  among  extra- abdominal  sites,  they 
have  been  discovered  in  the  fine  capillaries  of  the  walls 
of  the  alveoli  of  the  lungs  and  even  giving  rise  to  a 
form  of  chronic  interstitial  pneumonia.     (Chaker.) 

The  blood  in  the  haemoptysis  due  to  this  condition 
contains  ova.  Griesinger  has  also  reported  the  presence 
of  ova  in  the  blood  circulating  through  the  heart. 


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BILHARZIOSIS    OF   THE    FEMALE   GENERATIVE 
ORGANS. 

In  the  general  invasion  of  the  body  by  the  bilharzia 
worm  the  female  generative  organs  do  not  escape; 
and  here  all  the  changes  common  to  bilharziosis  of 
mucous  membranes  may  occur.  In  my  own  personal 
experience  cases  involving  all  parts  of  the  tract  from 
the  vulva  to  the  internal  os  uteri  have  been  met  with. 

On  the  vulva,  papillomatous  masses,  much  resem- 
bling venereal  warts  at  first  sight,  are  most  common. 
A  bilharzial  infiltration  of  the  skin  around  the  vaginal 
orifice  may  be  associated  with  these  masses.  Or  an 
area  of  crumbling  ulceration,  involving  a  triangular 
space  including  the  upper  edge  of  the  hymen  and  the 
vestibule,  and  even  extending  into  the  clitoris  and 
destroying  it,  may  occur  and  cause  considerable  de- 
struction of  tissue  in  this  situation.  The  urethral 
orifice  may  be  completely  surrounded  by  such  an 
ulceration.  Sometimes  the  ulceration  takes  on  an 
excessive  growth  at  the  edges,  and  may  easily  be  mis- 
taken for  epithelioma.     (Figs.   18,   19,  20.) 

Within  the  vagina,  the  general  infiltration  of  the 
mucous  membrane  with  wet  sea-sand  deposits  and 
much  redundancy  of  the  membrane  is  the  most  usual 

73 


74  BILHABZIOSIS. 

change,  though  ranges  of  papillomatous  outgrowths 
may  also  be  found.  A  certain  proportion  of  cases 
present  signs  of  ulceration  and,  in  rare  instances,  a 
vesico -vaginal  fistula  is  formed  by  extension  of  a 
marked  bilharziosis  of  the  bladder  through  the 
anterior  vaginal  wall. 

Firm  polypoid  excrescences  are  not  unfrequently 
found  on  the  cervix  uteri,  their  pedicles  sometimes 
extending  within  the  cervical  canal  nearly  to  the  in- 
ternal os.  In  most  of  these  cases  there  is  some  infil- 
tration of  the  mucous  membrane  of  the  vagina,  often 
only  quite  high  up  in  the  fornices,  which  gives  one  a 
clue  to  the  diagnosis,  for  at  first  sight  early  epithelio- 
matous  growths  may  be  suspected.     (Fig.  21.) 

Small  fibro-adenomatous  tumours,  containing  bil- 
harzia  ova,  may  also  occur  on  the  cervix  ;  but,  so 
far,  no  evidence  of  infiltration  of  the  mucous  mem- 
brane of  the  uterus  itself  is  forthcoming,  though 
several  suspected  scrapings  have  been  examined. 

Whenever  possible  these  various  manifestations 
must  be  treated  by  excision,  scraping,  or  removal  as 
the  case  demands. 

Symmers  has  noted  the  occurrence  of  a  mass  of 
fibrous  tissue  involving  the  ovary  and  the  upper  edge 
of  the  broad  ligament  in  a  young  child.  Microscopical 
examination  disclosed  the  presence  of  bilharzia  ova. 


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76  BILHARZIOSIS. 

filtrated  also,  and  is  gradually  converted  into  a  hard 
scar  tissue,  the  openings  of  the  various  sinuses  being 
surrounded  by  prominent  buttons  of  granulation 
tissue. 

The  only  possible  treatment  of  these  cases  is  to 
dissect  out  the  whole  track  completely,  cutting  wide 
of  the  thick  fibrous  tissue  tubes  through  healthy 
tissue.  In  most  situations  where  these  sinuses  occur, 
such  a  radical  operation  is  not  possible,  in  which  case 
the  sinuses  must  be  freely  laid  open  and  very  thor- 
oughly scraped  with  a  sharp  spoon,  until  every  vestige 
of  granular  tissue  is  removed,  and  the  wound  then 
plugged  and  allowed  to  heal  from  the  bottom.  Many 
operations  may  be  required,  as  each  new  track  must 
be  opened  up  as  it  forms,  and,  in  the  end,  a  large  area 
may  be  transformed  into  a  mass  of  scar  tissue  extend- 
ing over  a  considerable  area.     (Fig.  22.) 

Sometimes  these  independent  sinuses  acquire  a 
secondary  connection  with  adjoining  cavities,  more 
often  with  the  rectum  than  with  either  bladder  or 
urethra,  in  which  case  they  lose  all  their  individuality 
and  become  bilharzial  fistulas  of  the  more  ordinary 
type,  though  there  may  not  be  any  affection  of  the 
viscus  with  which  they  communicate. 

On  the  skin  surface  one  sometimes  sees  patches, 
made  up  of  a  number  of  small  rounded  elevations 
closely  packed  together,  on  a  darkly  pigmented  base ; 
and,  again,  a  peculiar  form  of  ulceration  may  be 
present.  "A  few  small  discrete  infiltrated  spots  of 
dark  colour,  raised  above  the  level  of  the  skin,  may 


Fig.  21.  Fig.  23. 

Fig.  21.—  Bilharzial  papilloma  growing  from  the  posterior  lip  of  the  cervix 
uteri.  The  case  was  diagnosed  epithelioma,  and  vaginal  hysterectomy 
was  performed. 

(Photograph  of  the  uterus  removed  by  the  Author  in  Kasr-el-Ainy  Hospital, 
Cairo.  The  case  icas  figured  and  described  in  the  second  volume  of  the 
Records  of  the  School  of  Medicine.  Cairo,  1904.) 

Fig.  23.— Epithelioma  around  the  anus  originating  on  the  site  of  old 
extensive  bilharzial  disease  in  and  around  the  lower  end  of  the 
rectum.  Scars  of  old  bilharzial  sinuses  are  seen  scattered  through- 
out the  surrounding  skin. 

(Photograph  of  a  case  in  the  Author's  wards  in  Kasr-el-Ainy  Hospital,  Cairo.) 


Fig.  22.—  Extensive  scarring  left  after  multiple  operations  on  bilharzial 
sinuses,  originating  in  the  subcutaneous  tissue.  The  whole  area 
was  riddled  with  sinuses  which  had  no  connection  with  either 
rectum  or  urethra. 

(Photograph  of  a  case  in  the  Author's  wards  in  Kasr-el-Ainy  Hospital,  Cairo.) 


SKIN  AND  SUBCUTANEOUS  TISSUES.  77 

occur.  These  spread  and  run  together,  and  having 
reached  a  certain  size,  break  down  and  form  ulcers, 
which  spread  in  an  irregular  way  and  very  slowly. 
The  surrounding  skin  is  healthy,  though  there  may  be 
outlying  bilharzial  papules.  The  edges  of  the  ulcer 
are  irregular,  crenated  and  sinuous,  and  they  show 
no  sign  of  healing,  though  there  may  be  scar  tissue 
around  them  from  pre-existing  bilharzia.  The  ulcer  is 
somewhat  raised,  and  its  base  is  irregular,  and  the  dis- 
charge is  scanty  and  serous.  It  is  quite  painless  and, 
on  scraping,  one  finds  a  gelatinous  bilharzial  tissue 
coated  with  feeble  granulations.  This  granular  tissue 
burrows  into  healthy  tissues  and  forms  little  pockets 
below  and  beyond  the  borders  of  the  ulcer."  (Milton.) 
The  only  satisfactory  treatment  is  complete  excision  or 
vigorous  scraping,  as  before  explained. 

In  certain  situations,  particularly  around  the  anus 
and  on  the  site  of  ulceration  of  the  glans  penis,  an 
epithelioma  sometimes  develops.  The  structure  of  such 
growths  is  that  usually  associated  with  epithelioma ; 
but  bilharzia  ova  are  freely  distributed  throughout  the 
section.  (Kartulis.)  As  in  the  case  of  bilharziosis 
with  scirrhus  cancer  (page  38),  the  true  significance 
of  this  association  is  not  yet  properly  determined. 
(Figs.  23  and  24.) 

The  treatment  of  such  cases  resolves  itself  into 
that  of  epithelioma. 


78  BILEARZIOSIS. 

BIBLIOGRAPHY. 

A  very  complete  bibliography  of  bilharziosis  has 
been  compiled  by  Looss  in  Mense's  "  Handbuch  der 
Tropen-krankheiten,"  and  since  that  publication  a  series 
of  articles  has  appeared  in  the  Transactions  of  the 
Egyptian  Medical  Congress  1902.  Papers  on  interest- 
ing cases  by  W.  H.  Clayton- Greene  in  the  Lancet  of 
December  17th,  1904,  P.  Gr.  Stock  in  the  Lancet  of 
September  29th,  1906,  E.  C.  Freeman  in  the  Journal 
of  the  Royal  Army  Medical  Corps,  page  145,  vol. 
for  1905,  and  a  most  interesting  and  instructive  article 
on  "  A  remarkable  case  of  Bilharziosis,"  by  Professor 
Symmers,  in  the  ''Studies  in  Pathology."  written  by 
Ahinini  to  celebrate  the  Quatercentenary  of  the  Uni- 
versity of  Aberdeen,  1906,  may  also  be  mentioned. 


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